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MEDICAL    TEXT-BOO  Kb 


PUBLISHED    BY 


LINDSAY  &  BLAKISTON,  PHILADELPHIA. 


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MANUAL  OF   THE   DISEASES 


THE    EYE. 


OPINIONS  OF  THE  MEDICAL  PRESS. 


From  the  London  Medical  Times  and  Gazette,  Aug.  14,  1869. 

"  We  have  been  fully  supplied  in  the  last  two  or  three  years  with  sys- 
tematic treatises  on  diseases  of  the  eye.  But  there  seems  still  to  be  room 
for  a  clear,  brief,  and  concise  yet  practically  full  manual  on  modern  oph- 
thalmic medicine  and  surgery,  such  as  might  serve  for  a  text-hook  fur  stu- 
dents and  a  companion  for  the  busy  practitioner.  This  Mr.  Lawson  ha.s 
supplied,  and  supplied  admirably  well.  Of  his  qualifications  for  the  ta-^k 
of  producing  such  a  work  it  would  be  superfluous  to  speak.  He  is  a  '  Past 
Master'  on  the  subject,  and  while  any  work  of  his  is  sure  of  a  favorable 
reception,  he  has  taught  the  profession  to  judge  him  by  a  high  standard 
of  excellency,  and  so  judged  the  book  we  now  notice  will  certainly  not 
disappoint  its  readers.  Necessarily  brief  and  concise  as  to  details,  it  is 
admirably  clear  and  eminently  practical.  The  reader  feels  that  he  is  in 
the  hands  of  a  teacher  who  has  a  right  to  speak  with  authority,  and  who, 
if  he  may  be  said  to  be  positive,  is  so  from  the  fulness  of  knowledge  and 
experience,  and  who,  while  well  acquainted  with  the  writings  and  labors 
of  other  authorities  on  the  matters  he  treats  of,  has  himself  practically 
worked  out  what  he  teaches." 

From  the  British  Medical  Journal,  Jnli/  24,  18(59. 

"  We  congratulate  Mr.  Lawson  on  the  production  of  such  an  excellent 
work  on  ophthalmic  diseases  as  this.  Without  depreciating  the  large  and 
valuable  treatises  on  this  subject  that  have  recently  appeared,  we  have 
long  felt  that  a  manual  was  wanted  which  would  serve  as  a  teat-hook  for 
stndetits,  and  also  should  form  a  trustworthy  guide  for  practitioners  in 
dealing  with  diseases  of  the  eye.  AVell  has  Mr.  Lawson  supplied  this 
want.  He  has  described  the  various  aflfeutions  of  the  eye,  briefly  but  j-et 
clearlj',  and  from  the  large  experience  he  has  acquired  as  surgeon  to  the 
Royal  London  Ophthalmic  Hospital,  Moorfields,  he  has  made  his  work 
thorongkly  ■practical.  The  profession  will  find  this  manual  just  the  sort 
of  work  they  want  on  eye  diseases,  while  to  the  student  it  will  be  invalu- 
able as  a  text-book.'' 

From  the  Practitioner,  August,  1869. 

"This  handy  and  beautifully  printed  volume  is  as  good  in  the  quality 
of  its  contents  as  it  is  attractive  to  the  eye.  Mr.  Lawson  has  long  been 
known  as  an  ophthalmic  surgeon,  he  has  enjoyed  a  long  experience,  and 
he  has  the  faculty  of  telling  his  story  clearly.  He  has  here  given  us  a 
manual  of  moderate  size,  in  which  the  practitioner  will  find  ,«hort  and 
clear  descriptions  and  directions  for  the  treatment  of  every  kind  of  eye 
disease.  The  work  is  sure  to  become  very  popular,  and  to  enjoy  a  large 
circulation.'' 


DISEASES    AND   INJURIES 


THE   EYE: 


MEDICAL  AND  SURGICAL  TREATMENT. 


GEORGE  LAWSON,  F.R.C.S., 

SUROEON   TO   THE   ROYAL   LONDON   OPHTBALMIC   HOSPITAL,   MOORFIELDS, 
AND    ASSISTANT-SCROEON   TO   TUB  MIDDLESEX  HOSPITAL. 


PHILADELPHIA: 
LINDSAY    &    BLAKISTON. 

186  9. 


CAXTON   PRESS    OF    SHERMAN    ft    CO 


I  Go 


PREFACE. 


In  this  Manual  is  comprised  a  brief  account  of  all 
the  medical  and  surgical  affections  of  the  Eje,  with  the 
treatment  essential  for  their  relief.  Each  subject  is 
discussed  in  a  separate  section,  under  its  own  peculiar 
heading. 

In  the  description  and  treatment  of  the  various  dis- 
eases, I  have  not  o\\\j  given  the  results  of  mj^  own  ex- 
perience, but  I  have  carefully  recorded  special  points 
in  the  practice  of  my  colleagues  at  the  Roj'al  London 
Ophthalmic  Hospital,  and  have  made  frequent  reference 
to  the  labors  of  the  Continental  ophthalmic  surgeons. 

The  scope  of  this  work  forbids  profusion  of  detail. 
Wh^n,  therefore,  fuller  information  is  required,  I  must 
refer  the  reader  to  the  "  Treatise  on  the  Eye,"  by  Mr. 
Soelberg  Wells,  or  to  the  "Natmal  and  Morbid  Changes 
of  the  Human  Eye,"  by  Mr.  Bader. 

At  the  end  of  the  book  I  have  added  a  Formulary  of 
Prescriptions,  and  also  a  page  of  Test-types,  reduced 
from  those  designed  by  Dr.  Orestes  M.  Pray,  of  New 
York,  to  aid  in  the  diagnosis  of  astigmatism.     In  the 

1* 


VI  PREFACE. 

original,  each  letter  is  two  inches  square,  and  is  com- 
posed of  either  vertical,  horizontal,  or  oblique  lines  set 
at  different  angles. 

To  my  friend  Dr.  Workman  I  return  my  warmest 
thanks  for  the  help  he  has  kindl}-  given  me  in  revising 
the  proof-sheets  before  they  passed  through  the  press. 

12  Harley  Street,  Cavendish  Square,  "W. 
June,  1869. 


CONTENTS. 


CHAPTER  I. 

DISEASES   OF   THE   CONJUNCTIVA. 

PAGE 

Catarrhal  Ophthalmia — Chronic  Ophthalmia — Pustular  Oph- 
thalmia— Purulent  Ophthalmia  of  Newly-born  Infants — 
Purulent  or  Contagious  Ophthalmia — Gonorrhoeal  Ophthal- 
mia— Diphtheritic  Ophthalmia — Granular  Lids — Syndec- 
tomy — Pterygium — Pinguecula — Dermoid  Tumors  of  the 
Conjunctiva — Cysts  of  the  Conjunctiva — Warts  of  the  Con- 
junctiva— Injuries  of  the  Conjunctiva — Ecchymosis  of  the 
Conjunctiva — Lacerations  of  the  Conjunctiva,        .         .     13-42 

CHAPTER  II. 

DISEASES    OF    THE    CORNEA    AND    SCLEROTIC. 

Corneitis — Chronic  Interstitial  Corneitis — Strumous  Corneitis 
— Diffuse  Suppurative  Corneitis — Hj-popion — Onyx — Ab- 
scess of  the  Cornea — Marginal  Corneitis — Phlyctenular 
Ophthalmia — Corneo-Iritis — Ulcers  of  the  Cornea — Super- 
ficial Ulcers  of  the  Cornea — Superficial  Nebulous  Ulcers — 
Superficial  Transparent  Ulcers — Deep  Ulcers  of  the  Cor- 
nea— Sloughing  Ulcers — Crescentic  or  Chiselled  Ulcers — 
Chronic  Vascular  Ulcers — Fistula  of  the  Cornea — Nebula 
of  the  Cornea — Leucoma  of  the  Cornea — Opacity  of  the 
Cornea  from  Lead — Conical  Cornea — Kerato-globus — Sta- 
phyloma of  the  Cornea,  partial  and  complete — Ciliary  Sta- 


Vlll  CONTENTS. 

PAUE 

pbylbma — Cyclitis — Episcleritis — Injuries  of  the  Cornea 
and  Sclerotic — Foreign  Bodies  on  the  Cornea — Abrasions  of 
the  Cornea — Penetrating  Wounds  of  the  Cornea  and  Scle- 
rotic— Kupture  of  the  Eye  through  the  Sclerotic,  .         .     43-93 


CHAPTER  III. 

DISEASES    OF    THE    IRIS    AND    VITREOUS    HFMOR. 

Iritis — Classification  of — General  Symptoms  of — Syphilitic 
Iritis — Eheumatic  Iritis — Serous  Iritis — Suppurative  Iritis 
— Traumatic  Iritis — Cysts  of  the  Iris — Cysticercus  on  the 
Iris — Melanotic  Sarcoma  or  Carcinoma  of  Iris — Functional 
Derangements  of  the  Iris — Mydriasis — Myosis — Calabar 
Bean — Operations  on  the  Iris — Iridectomy — Artificial  Pupil 
—1.  "With  a  Broad  Needle  and  Tyrrell's  Hook— 2.  By  Iri- 
dodesis  or  Ligature  of  the  Iris — 3.  By  Incision  of  the  Iris — 
4.  By  Excision  of  a  Triangular-shaped  piece  of  Iris — In- 
juries to  the  Iris — Hemorrhage  into  the  Anterior  Chamber 
— Coredialysis — Prolapse  of  the  Iris — Irido-Choroiditis — 
Choroido-Iritis  —  Sympathetic  Ophthalmia  —  Glaucoma  — 
The  Acute  and  Subacute  Inflammatory  Glaucoma — The 
Chronic  or  Simple  Glaucoma — The  Consecutive  or  Second- 
ary Glaucoma — How  to  ascertain  the  Tension  of  the  Globe 
— Tremulous  Iris — Coloboma  of  the  Iris — Diseases  of  the 
Vitreous — Hj-alitis — Muscje  Yolitantes — Opacities  of  the 
Vitreous — Sparkling  Synchysis — Fluidity  of  the  Vitreous 
— Foreign  Bodies  in  the  Vitreous — Hemorrhage  into  the 
Vitreous, 93-148 

CHAPTER  IV. 

DISEASES   OF    THE   CRYSTALLINE   LENS. 

Cataract — Causes  of — Classification  of — Hard  and  Soft  Cata- 
racts— Congenital  or  Infantile  Cataract — Involuntary  Os- 
cillations of  the  Globe — Operations  for  Soft  Cataract — Oper- 
ation by  Solution — Linear  Extraction — Suction  Operation 


CONTENTS.  IX 

PAGE 

— Hard  Cataracts — Varieties  of — Nuclear,  Striated,  Black, 
and  Senile  Cataracts — Operations  for  Hard  Cataracts — Flap 
Extraction  Operation — Accidents  which  may  happen  in 
Flap  Extraction  of  Cataract — Remarks  on  Flap  Extraction 
— The  Traction  Operation — Von  Graefe's  modified  Linear 
Extraction — Mooren's  Extraction  Operation — Jacobson's 
Extraction  Operation — Pagenstecher's  Operation  for  ex- 
tracting the  Lens  in  its  Capsule — Macnamara's  Operation 
for  Cataract — Treatment  of  the  Eye  after  an  Extraction  of 
the  Cataract— The  Casualties  which  may  occur  after  an  Ex- 
traction of  a  Hard  Cataract — Capsular  Cataract — Capsulo- 
Lenticular  Cataract — Diabetic  Cataract — Fluid  Cataract — 
Traumatic  Cataract — Secondary  Cataract — Capsular  Opaci- 
ties— Treatment  of — Dislocations  of  the  Lens — 1.  Into  the 
Anterior  Chamber — 2.  Into  the  Vitreous — 3.  Beneath  the 
Conjunctiva — Partial  Dislocations  of  the  Lens,  .         .     149-195 


CHAPTER  V. 

DISEASES    OF    THB    RETINA,    CHOROID,    AND    OPTIC    NERVE. 

Hyperaemia  of  the  Retina — Retinitis — Retinitis  Albuminurica 
— Retinitis  Syphilitica — Retinal  Apoplexy — Retinitis  Pig- 
mentosa— Detachment  of  the  Retina — Embolism  of  the  Cen- 
tral Artery  of  the  Retina — Tumors  of  the  Retina — Glioma 
of  the  Retina — Cysts  of  the  Retina — Diseases  of  the  Choroid 
— Disseminated  or  Exudative  Choroiditis — Sclerotico-Cho- 
roiditis  Posterior — Suppurative  Choroiditis — Deposits  of 
Bone  on  the  Choroid — Tubercles  in  the  Choroid — Hemor- 
rhage from  the  Choroid — Injuries  of  the  Choroid — Hemor- 
rhage between  the  Choroid  and  Retina — Hemorrhage  be- 
tween the  Choroid  and  Sclerotic — Hemorrhage  into  the 
Vitreous — Tumors  of  the  Choroid — Sarcoma  of  the  Choroid 
— Medullary  Cancer  of  the  Choroid— Diseases  of  the  Optic 
Nerve — Descending  Optic  Neuritis — Neuro-Retinitis — At- 
rophy of  the  Optic  Nerve — Amaurosis — Causes  of — Am- 
blyopia— Hemeralopia — Snow-blindness — Color-blindness — 
To  ascertain  the  Field  of  Vision — The  Ophthalmoscope — 
How  to  work  with  the  Ophthalmoscope — Lateral  or  Focal 
Illumination  of  the  Eye,       ......     19-J-260 


CONTENTS. 


CHAPTER  VI. 

ANOMALIES   OF   REFRACTION   AND   DISEASES   OF    ACCOMMODATION. 

PAGE 

Accommodation — Myopia — Ophthalmoscopic  appearances  of 
a  Myopic  Eye — Treatment  of  Myopia — Degree  of  Myopia — 
General  Rules  for  Selection  of  Glasses — General  Directions 
for  Myopic  Patients — Hypermetropia — Treatment  of  Hy- 
permetropia — To  ascertain  the  degree  of  Hypermetropia — 
Peculiarities  of  the  Hypermetropic  Eye  —  Presbyopia  — 
Treatment  of  Presbyopia — Astigmatism — Irregular  Astig- 
matism— Regular  Astigmatism — Asthenopia — Causes  of — 
Treatment  of  Asthenopia, 2G0-282 


CHAPTER  VII. 

STRABISMUS. 

Strabismus — Causes  of — To  ascertain  the  Degree  of — Con- 
vergent Strabismus — Causes  of — Divergent  Strabismus — 
Causes  of — Treatment  of  Strabismus — The  Moortields  Ope- 
ration for  Strabismus — Von  Graefe's  Operation  for  Strabis- 
mus— Liebreich's  Operation  for  Strabismus — Treatment  of 
Strabismus  after  the  Operation — Divergent  Strabismus  fol- 
lowing division  of  the  Internal  Recti  Muscles — Operation 
for  bringing  forward  the  Internal  Rectus  Muscle — Paralysis 
of  the  Ciliary  Muscle — Spasm  of  the  Ciliary  Muscle — Diplo- 
pia— Homonymous  Diplopia — Crossed  Diplopia — The  Ac- 
tion and  Uses  of  Prisms — To  ascertain  the  presence  of 
Binocular  Vision — To  test  the  Strength  of  the  Muscles  of 
the  Eye — To  wear  as  Spectacles  to  correct  Diplopia — Para- 
lytic Aflcctions  of  the  Muscles  of  the  Eye — Causes  of — 
Paralysis  of  the  Third  Nerve— Paralysis  of  the  Fourth 
Nerve — Paralysis  of  the  Sixth  Nerve — Treatment  of  Para- 
lytic Affections  of  the  Muscles  of  the  Eye,  .         .         .     282-312 


CONTENTS.  XI 


CHAPTER  VIII. 

SPECIAL    INJURIES    OF    THE    EYE. 

PAGE 

Foreign  Bodies  within  the  Eye — Injuries  of  the  Eye  from 
Escharotics — Injuries  from  Mortar,  Lime,  and  Plaster — 
Burns  and  Scalds  of  the  Eye — Injuries  from  Strong  Sul- 
phuric and  Nitric  Acid — From  Vinegar,  dilute  Acetic  Acid, 
or  any  of  the  weak  Acids — Injuries  from  Percussion  Caps, 
Gunpowder,  and  Small  Shot — Excision  of  the  Eye — Arti- 
ficial Eyes — Directions  for  wearing  Artificial  Eyes,    .     313-326 

CHAPTEPv  IX. 

DISEASES   OF   LACHRYMAL   APPARATUS. 

Epiphora — Causes  of — Chronic  Inflammation  of  Lachrymal 
Sac — Treatment  of — Stricture  of  Lachrymal  Canal — Sites 
of  Stricture  of — Treatment  of — Acute  Inflammation  of  the 
Lachrymal  Sac — Treatment  of — Fistula  of  the  Lachrymal 
Sac — Epiphora  from  Mechanical  Obstruction  by  Tumors — 
To  slit  up  the  Canaliculus — Obliteration  of  the  Lachrymal 
Sac — Removal  of  the  Lachrymal  Gland — Diseases  of  the 
Lachrymal  Gland — Inflammation  of  the  Lachrymal  Gland 
— Cysts  of  the  Lachrymal  Gland — Fistula  of  the  Lachrymal 
Gland — Chronic  Enlargement  of  the  Lachrymal  Gland — 
Treatment  of, 327-341 

CHAPTER  X. 

DISEASES   OF   THE   EYELIDS. 

Tinea  Tarsi — Hordeolum — Eczema  of  the  Lids — Trichiasis — 
Distichiasis — Operation  for  the  Removal  of  the  Eyelashes 
— Entropion  —  Spasmodic  Entropion  —  Chronic  Entropion 
— Causes  of — Treatment  of — Ectropion — Causes  of — Treat- 
ment of — Paralytic  and  Spasmodic  Aftections  of  the  Eye- 
lids—  Ptosis  —  Complete   and   Partial  —  Paralysis  of   the 


XU  CONTENTS. 

PAGE 

Orbiculiiris  Muscle  —  Blepharospasm — Ulcerations  of  the 
Eyelids — Syphilitic  Ulcers  of  the  Eyelid — Treatment  of— 
Kodent  Cancer  of  the  Eyelid — Epithelial  Cancer  of  the  Eye- 
lid— Treatment  of  Epithelial  and  liodent  Cancer — Tumors 
of  the  Eyelid — Tarsal  Cysts — Naevus  of  the  Eyelid — Seba- 
ceous or  Dermoid  Cysts — Epicanthus — Injuries  of  the  Eye- 
lids— Ecchymosis  of  the  Eyelid — Abscess  of  the  Eyelid — 
"Wounds  of  the  Eyelid — Kesults  of  Injuries  and  Ulcera- 
tions of  the  Eyelids — Anchyloblepharon — Treatment  of — 
Syrablepharon — Treatment  of, 342-378 


CHAPTER  XI. 

DISEASES   OF   THE   ORBIT. 

Abscess  of  the  Orbit — Acute  and  Chronic — Treatment  of — 
Fractures  of  the  Bones  of  the  Orbit  —  Foreign  Bodies  in 
the  Orbit — Effects  of — Treatment  of — Penetrating  Wounds 
of  the  Orbit — Periostitis  of  the  Orbit — Treatment  of — Ne- 
crosis and  Caries  of  the  Orbit — Aneurism  of  the  Orbit — 
True  and  False  Aneurism  of  Orbit — Diffuse  or  Consecutive 
Aneurism  of  Orbit — Aneurism  by  Anastomosis  of  Orbit — 
Exophthalmic  Goitre — Treatment  of — Tumors  of  the  Orbit 
— 1.  Those  which  originate  within  the  Orbit — 2.  Those 
which  commence  within  the  Eye — 3.  Those  which  have 
their  Origin  beyond  the  eye  or  Orbit — Treatment  of  Tu- 
mors of  the  Orbit — Acute  Inflammatory  Exudation  into 
the  Orbit — Distension  of  the  Frontal  Sinus — Anatomy  of 
Frontal  Sinus — Causes  of  Distension  of  Frontal  Sinus — 
Treatment  of  Distension  of  Frontal  Sinus, .         .         .     379-414 

Formulary  of  Prescriptions,    .......  415 

Page  of  Test-Types  for  Astigmatism, 427 


MANUAL 


DISEASES  OF  THE  EYE. 


CHAPTER  I. 

DISEASES    OF    THE    CONJUNCTIVA. 

Catarrhal  Ophthalmia — Acute  Conjunctivitis — is  an 
inflammation  of  the  conjunctiva  covering  the  eye  and 
lining  the  lids.  It  may  come  on  without  any  apparent 
cause,  or  it  may  be  produced  by  rapid  alternations  of  tem- 
perature, or  by  exposure  of  the  eye  to  cold.  Catarrhal 
ophthalmia  will  sometimes  assume  an  epidemic  character, 
and  large  numbers  in  the  same  locality  will  suffer  from  it ; 
or  it  will  attack  every  member  of  a  family  in  succession, 
notwithstanding  that  due  precautions  have  been  taken  to 
prevent  its  spreading  by  direct  communication. 

Symptoms. — A  feeling  of  grittiness,  as  if  dust  or  fine 
sand  were  in  the  eye,  wath  some  stiffness  of  the  lids.  The 
conjunctiva  becomes  red,  and  this  increase  of  vascularity 
generall3^  commences  from  the  circumference  of  the  globe, 
and  fades  as  it  approaches  the  cornea.  In  the  advanced 
stage  of  this  affection  the  white  of  the  ej^e  becomes  of  one 
uniform  red  color.  The  redness  is  superficial,  and  of  a 
brighter  and  darker  shade  than  that  caused  by  inflamma- 

2 


14  DISEASES    OF   THE    CONJUNCTIVA. 

tioii  of  the  deeper  structures  of  the  eye,  for  which  it  can 
hardly  be  mistaken.  There  is  an  increased  secretion  from 
the  surfaces  of  the  eye  and  lids ;  at  first  only  of  mucus, 
but  afterwards  of  muco-pus,  small  quantities  of  which  will 
collect  in  little  beads  over  the  caruncle  at  the  inner  angle 
of  the  eye,  or  form  little  scabs  on  the  edges  of  the  lids  by 
caking  on  the  eyelashes.  If  the  lower  lid  be  drawn  down 
by  the  finger,  one  or  two  streaks  of  pus  or  lymph  will  be 
pften  seen  in  the  oculo-palpebral  fold.  The  patient  com- 
plains that  the  lids  are  sticky,  and  that  in  the  morning 
they  are  gummed  together  by  dried  secretion.  On  look- 
ing at  the  eyes,  there  is  a  peculiar  sticky  and  gummy  ap- 
pearance which  is  quite  characteristic  of  the  disease. 
There  is  often  associated  with  these  symptoms  chemosis 
of  the  conjunctiva  and  swelling  of  the  lids.  The  con- 
junctiva looks  blown  np  from  the  serous  effusion  into  the 
subjacent  cellular  tissue,  sometimes  to  an  extent  sufllcient 
to  make  the  cornea  appear  sunken  below  it.  The  cornea 
is  clear,  and  the  pupil  is  active.  The  rapid  action  of  the 
pnpil  will  at  once  decide  that  the  inflammation  is  super- 
ficial, and  that  the  iris  is  not  affected  by  it. 

Catarrhal  ophthalmia  usually  commences  in  both  eyes 
simultaneousl}' ,  or  one  eye  may  be  attacked  a  little  in  ad- 
vance of  the  other,  but  it  is  seldom  that  this  disease  is 
limited  to  only  the  one  eye.  In  this  respect  catarrhal  oph- 
thalmia oflers  a -marked  difference  from  gonorrhoeal  oph- 
thalmia, which  is  generall}^,  in  the  first  instance,  strictly 
confined  to  the  one  eye.  (See  Gonorrhceal  Ophthalmia, 
page  22.) 

Prognosis. — This  affection  is  usually  very  amenable  to 
proper  treatment,  and  the  eye&  will  recover  without  a 
trace  of  the  disease  remaining.  But  if  no  treatment  be 
adopted,  or  unsuitable  remedies  be  used,  the  conjunctival 
inflammation  may  extend  to  the  cornea,  and  corneitis, 
with  superficial  or  deep  ulcerations,  may  follow. 


CHRONIC    OPHTHALMIA.  15 

Treatment. — The  ej^es  should  be  bathed  every  two  or 
three  hours,  or  oftener  if  the  case  is  severe,  with  a  lotion 
of  alum,  or  sulphate  of  zinc  and  alum  (F,  38,  39,  40), 
taking  care  that  with  each  application  a  little  is  allowed 
to  flow  into  the  eyes.  In  the  intervals  between  the  times 
for  using  the  lotion,  the  ej^es  may  be  bathed  with  cold 
water,  to  keep  them  free  from  the  discharge.  A  solution 
of  nitrate  of  silver,  gr.  1  or  gr.  2,  ad  aquae  ^  1,  is  very 
useful  in  catarrhal  ophthalmia,  and  especially  in  those 
cases  where  there  is  chemosis  of  the  conjunctiva  and 
swelling  of  the  lids.  Two  or  three  drops  should  be 
dropped  into  the  ej^e  twice  a  daj'^,  and  every  two  or  three 
hours,  or  oftener  if  necessary,  the  eyes  should  be  cleansed 
from  discharge  by  bathing  them  with  cold  water.  To  pre- 
vent the  gumming  together  of  the  eyelids  during  sleep,  a 
little  unguent,  cetacei  should  be  smeared  along  their  tarsal 
borders  every  night.  At  the  commencement  of  the  attack 
the  bowels  should  be  acted  on  by  some  pui-gative ;  and  if 
the  patient  is  hot  and  thirsty,  an  alkaline  or  effervescing 
draught  (F.  53,  55)  may  be  prescribed,  but,  as  a  rule, 
tonics,  such  as  bai'k,  quinine,  or  iron,  will  be  required; 
and  these  are  given  with  most  benefit  after  the  first  febrile 
symptoms  which  often  usher  in  an  attack  of  catarrhal 
ophthalmia  have  passed  away. 

Chronic  Ophthalmia  may  be  consequent  on  catarrhal 
ophthalmia,  the  acute  disease  subsiding  into  a  chronic 
form;  but  this  is  quite  exceptional.  Chronic  ophthalmia 
generally  occurs  in  patients  who  are  below  the  standard 
of  health,  and  in  those  who  have  to  earn  their  living  by 
the  long-continued  use  of  their  eyes  at  fine  work. 

Symptoms. — The  eye  has  a  reddish  and  irritable  appear- 
ance ;  it  will  not  face  the  light  without  a  sense  of  discom- 
fort and  watering.  The  caruncle  and  edges  of  the  lids 
often  look  red  and  prominent,  and  the  secretion  of  the 


IG  DISEASES    OF   THE    CONJUNCTIVA. 

mucous  surfaces  of  the  lids  and  globe  is  slightly  increased. 
Reading  or  fine  work  soon  tires  the  e^^e,  and  causes  it  to 
flush  up.  The  patient  is  generallj'  more  or  less  out  of 
health ;  oftentimes  used  up  from  Avant  of  rest. 

Treatment. — When  there  is  reason  to  believe  that  over- 
use of  the  eyes  has  been  the  exciting  cause  of  the  disease, 
rest  must  be  strictly  enjoined.  Close  reading,  the  casting 
up  of  figures,  and  all  fine  work  should  be  forbidden.  The 
state  of  the  patient's  health  should  be  improved,  and  an}^ 
irregularity  in  the  discharge  of  the  functions  of  the  differ- 
ent organs  of  the  bod}^  should  be,  as  far  as  possible,  cor- 
rected. 

Local  AjjjMcations. — When  there  is  any  extra  secretion 
from  the  mucous  surfaces  of  the  lids  or  eye,  mild  stimu- 
lating drops  or  lotions  do  good.  Two  or  three  drops  of 
the  guttse  argenti  nitratis  (F.  16),  or  of  zinci  sulphatis 
(F.  20),  may  be  dropped  into  the  eye  twice  a  da^'.  Lo- 
tions Avith  alum,  or  with  alum  and  sulphate  of  zinc  com- 
bined (F.  39,  40),  are  very  efficacious.  A  weak  solution 
of  the  acetate  of  lead  (F.  42),  provided  there  is  no  abra- 
sion of  the  cornea,  will  be  often  found  very  useful.  The 
tarsal  edges  of  the  lids  should  be  anointed  at  night  Avitli 
a  little  unguent,  cetacei,  to  prevent  their  gumming  to- 
gether; or  if  there  is  much  secretion  from  the  Meibomian 
follicles,  the  unguent,  hydrarg.  nitratis  dilut.  (F.  102) 
may  be  advantageously  used.  When  there  is  much  dread 
of  light,  stimulating  applications  to  the  e^'e  fail  to  do 
good,  and  are  apt  to  excite  considerable  irritation.  In 
chronic  ophtlialmia,  counter-irritation  will  be  frequently 
found  beneficial.  A  small  blister  of  emplast.  cantharidis, 
or  a  piece  of  Brown's  tilistering  tissue  of  the  size  of  a 
shilling,  may  be  applied  to  the  temple,  or  behind  the  ear, 
and  repeated  in  two  or  three  nights  if  necessary'. 

If  the  remedies  named  fail  to  afford  relief,  a  seton  in 
the  temple  of  a  single  or  double  thread  of  thick  corded 


PUSTULAR    OPHTHALMIA.  17 

silk  will  occasionally  do  good.  The  setoii  should  not  be 
allowed  to  remain  more  than  three  or  four  weeks,  or  the 
ulceration  at  the  entrance  and  exit  of  the  thread  may 
cause  an  viusightly  scar.  In  cases  of  persistent  chronic 
ophthalmia  the  lids  should  be  everted  and  carefully  ex- 
amined for  granulations,  as,  if  the  conjunctiva  has  become 
granular,  the  ophthalmia  will  continue  until  the  granula- 
tions are  cured.     (See  Granular  Lids.) 

Pustular  Ophthalmia  is  a  mild  form  of  inflammation 
of  the  conjunctiva,  characterized  by  the  formation  of 
small  elevations  about  one  or  two  lines  from  the  margin 
of  the  cornea.  They  are  generally  of  a  reddish  color  at 
their  base,  and  of  a  yellowish-white  on  their  somewhat 
flattened  summits.  They  have  been  called  pustules,  but 
they  do  not  really  contain  pus  ;  if  pricked,  onl}^  a  little 
watery  fluid  will  exude  from  them.  The  conjunctiva  in 
their  vicinity  is  more  or  less  reddened,  and  sometimes 
one  or  two  small  red  vessels  may  be  seen  coursing  towards 
them.  There  may  be  only  one  of  these  so-called  pustules, 
or  there  mu}^  be  as  man}'  as  three  or  four  of  them.  There 
is  no  intolerance  of  light,  and  the  patient  seldom  com- 
plains of  more  than  a  feeling  of  grittiness  in  the  eye. 
One  peculiarit}^  of  pustular  ophthalmia  is  that  it  is  very 
apt  to  recur.  This  attection  is  quite  distinct  from  the 
true  phlyctenular  ophthalmia  described  in  the  chapter  on 
Diseases  of  the  Cornea. 

Treatment. — Attention  must  be  paid  to  the  general 
health  of  the  patient,  and,  if  necessary,  a  mild  aperient 
prescribed.  As  a  local  application,  any  mild  stimulant 
will  do  good.  A  little  calomel,  dusted  into  the  qjq  on  to 
the  pustules  with  a  camel's  hair  brush  every  or  every 
other  day  for  a  few  times,  will  be  found  a  very  eflScient 
remedy.  It  has  also  the  credit  of  preventing  a  recur- 
rence of  the  disease.     Lotions  of  the  acetate  of  lead  (F. 

2* 


18  DISEASES    OF   THE    CONJUNCTIVA. 

42),  or  of  sulphate  of  zinc,  ma}'  be  also  used  with  good 
effect. 

Purulent  Ophthalmia  of  Newly-born  Infants — 
Ojyhthalmia  neonatorum — is  one  of  the  most  important 
diseases  of  the  63^6  which  the  surgeon  can  have  under  his 
care.  When  rightly  treated  it  is  one  of  the  most  remedi- 
able, but  when  neglected,  or,  what  is  often  worse,  when 
unsuitable  and  improper  remedies  are  used,  it  is  one  of 
the  most  disastrous  of  all  the  inflammatory  affections  of 
the  eye.  The  responsibility  of  any  one  undertaking  a 
case  of  purulent  ophthalmia  who  is  not  thoroughly'  ac- 
quainted with  its  nature  and  treatment  is  very  great. 
Many  a  useful  life  has  been  blighted  in  the  first  mouth  of 
its  existence  by  irreparable  blindness,  which  might  have 
been  prevented  if  the  simple  means,  which  seldom  fail  to 
arrest  this  formidable  disease,  had  been  rightfull}-  applied. 
Purulent  ophthalmia  usually  commences  from  the  second 
to  the  seventh  day  after  birth.  Both  eyes  are  commonly 
atfected  simultaneously',  but  to  this  there  are  occasional 
exceptions ;  thus  one  eye  only  ma}'^  be  involved,  or  the 
first  eye  may  sufier  twelve  or  twenty-four  hours  in  ad- 
vance of  the  second. 

Symjitoms. — The  first  indication  of  the  disease  is  usu- 
ally detected  by  the  nurse,  who  notices  that  there  is  a 
slight  discharge  from  the  eyes,  and  that  the  edges  of  the 
lids  are  glued  together  during  sleep.  In  a  short  time, 
often  within  a  few  hours,  the  discharge  increases  greatly 
in  quantity  and  changes  in  quality  ;  it  first  becomes  muco- 
purulent, and  ultimatel}',  if  the  case  is  severe,  is  converted 
into  almost  pure  pus.  The  eyelids  now  become  red  and 
swollen,  and  their  tarsal  margins,  caked  together,  pen  up 
the  discharge,  which  accumulates  behind  the  lids,  and 
streams  over  the  cheeks  when  the  e^'es  are  opened.  The 
quantity  of  pus  which  literally  pours  from  between  the 


I'UKULENT    OPHTHALMIA    OF    INFANTS.  19 

ej^elids  in  a  bad  case,  and  the  rapidity  with  which  it  is 
secreted,  are  verj'  remarkable. 

In  the  slight  cases  of  puruleut  ophthahnia  the  discharge 
is  of  a  whitish  color  with  scarcely'  a  tinge  of  j^ellow,  and 
it  is  not  ver}^  abundant  iii  quantity.  In  the  very  severe 
forms  of  the  disease  the  discharge  is  of  a  deep  yellow 
color  and  very  profuse.  Between  these  extremes  there 
are  many  gradations. 

Prognosis. — When  a  child  suffering  from  purulent  oph- 
thalmia is  seen  sufficiently  early,  and  proper  remedies  are 
rightly  applied,  recover}^  is  almost  certain.  It  should, 
however,  be  remembered  that  cases  occasionally  occur  of 
so  severe  a  nature  that  all  treatment  is  unaA'ailable  to  ar- 
rest the  progress  of  the  disease,  and  one  or  both  ej^es  are 
rapidly  and  irrecoverably  destroj-ed.  In  such  instances 
it  will  generally  be  found  that  the  discharge  was  of  a 
deep  yellow  color,  very  copious,  and  that  it  commenced 
on  the  first  or  second  day  after  birth.  It  will  also  be 
probably  ascertained,  on  inquiry,  that  the  mother  had 
gonorrhoea  at  the  time  of  her  confinement,  or  leucorrha^a 
of  so  severe  a  type  that  the  discharge  was  yellow  and 
puriform. 

Treatment. — The  indications  for  treatment  are  to  wash 
away  the  discharge  from  the  ej^e  as  often  as  it  collects, 
and  to  use  some  astringent  lotion  to  arrest  the  re-secretion 
of  the  purulent  matter.  Lotions  of  alum,  or  of  sulphate 
of  zinc  and  alum  (F.  38,  40),  and  drops  of  nitrate  of  sil- 
ver, are  the  most  useful  astringents  in  purulent  ophthal- 
mia. The  lotion  which  I  generally  use  is  one  of  alum 
(F.  38).  The  mode,  however,  of  applying  the  remedies 
is  of  as  much  importance  as  the  remedies  themselves. 
The  lotion  should  be  gently  squirted  into  the  eye  with  an 
India-rubber  S3'i'inge  with  an  ivory  nozzle,  or  with  a  small 
glass  S3'ringe,  ever}"  half-hour  or  hour,  according  to  tlie 
severity  of  the  case,  the  object  being  to  thoroughh^  cleanse 


20  DISEASES   OF   THE    CONJUNCTIVA. 

the  eye  from  all  discharge  as  often  as  it  is  re-secreted. 
This  treatment  should  be  pursued  by  night  as  well  as  by 
daj^  The  intervals  between  the  use  of  the  lotion  ma}-  be 
increased  as  the  discharge  decreases  in  quantity.  The 
carrying  out  of  these  iusti'uctions  should  be  intrusted 
solely  to  the  nurse,  as  the  mother,  so  soon  after  her  con- 
finement, is  unfitted  for  the  duty,  and  rest  is  also  essen- 
tial for  her  in  order  to  insure  a  due  suppl}-  of  milk  for  the 
child. 

The  easiest  way  of  applying  the  lotion  is  as  follows : 
The  nurse  should  lay  the  child  on  her  laj:),  turning  its 
head  a  little  to  one  side  or  the  other,  according  to  the  eye 
she  is  going  to  wash  out.  "With  the  thumb  and  finger  of 
her  left  hand  she  geutl}'  separates  the  lids,  whilst  with 
the  right  hand  she  squirts  a  stream  of  the  lotion  into  the 
e3'^e  from  the  nasal  side,  allowing  it  to  run  away  from  be- 
tween the  lids  on  to  a  soft  napkin,  which  she  has  placed 
under  its  head  to  receive  it. 

If  the  case  is  very  severe,  the  surgeon  should  see  the 
child  once  or  twice  a  day  himself,  and  having  washed  the 
eye  thoroughly  from  all  discharge  with  a  stream  of  cold 
water,  he  should  drop  into  it  two  or  three  drops  of  a  solu- 
tion of  nitrate  of  silver  gr.  2  ad  aqua^  5  1,  and  order  the 
alum  lotion  to  be  continued  as  directed  during  his  ab- 
sence. In  some  cases,  where  the  nurse  is  verj'  awkward, 
and  cannot  rightly-  use  the  lotion  with  a  syringe,  it  may 
be  efficiently  applied  by  means  of  a  soft  camel's-hair 
brush.  From  time  to  time  a  little  unguent,  cetacei  should 
be  smeared  on  the  edges  of  the  lids,  to  prevent  their 
sticking  together. 

Evil  Results  of  Purulent  Ophthalmia.  —  The  great 
danger  in  this  disease  is  lest  the  inflammation,  which  was 
originally  confined  to  the  conjunctiva  of  the  lids  and 
globe,  should  extend  to  the  cornea.  When  this  happens, 
acute  corueitis  follows ;  the  cornea  becomes  at  firs-t  hazy, 


PURULENT    OPHTHALMIA.  21 

then  ulcerates  either  superficially  or  deeply,  or,  if  the 
case  is  very  severe,  a  large  portion  of  it  may  slough. 
As  the  result  of  such  casualties,  we  get  nebula,  leucoma, 
or  staphyloma  of  the  cornea.  Each  of  these  subjects 
will  be  found  fully  treated  of  under  their  respective  head- 


PuRULENT  Ophthalmia — Contagwus  Ophthalmia To 

this  disease  xevy  many  names  have  been  ai)ijlied,  but  the 
two  mentioned  are  sufficient  to  indicate  its  nature.  This 
form  of  ophthalmia  is  both  purulent  and  contagious.  It 
has  been  called  Egi/jjfian  Ophthalmia^  from  its  being  ever 
present  in  Egypt,  where  the  severest  types  of  the  disease 
are  to  be  constantly  found. 

In  its  mild  form  it  closely  resembles  catarrhal  ophthal- 
mia, for  which  it  may  be  mistaken ;  but  in  the  worst  cases 
it  almost  equals  in  severitj^  the  gonorrho^al  aflection  of 
the  eyes. 

Purulent  ophthalmia  commences  with  a  slight  discharge 
from  the  ej^e  and  swelling  of  the  lids.  The  discharge  soon 
increases  in  cpiautity  and  becomes  puriform,  the  conjunc- 
tiva gets  chemosed,  and  the  lids  grow  red,  shining,  and 
oedematous.  If  the  disease  progresses  unchecked,  the 
cornea  first  becomes  cloiidy,  then  ulcerates,  or  portions  of 
it  slough,  and  the  e}' e  is  destrojed.  The  peculiar  ten- 
dency of  purulent  ophthalmia  is  to  attack  masses  of 
people  who  are  congregated  together,  and  living  without 
due  attention  to  cleanliness  and  ventilation.  Hence  it  is 
that  the  disease  has  frequently  broken  out  amongst  sol- 
diers in  barracks,  amongst  the  poor  in  workhouses,  and 
in  large  pauper  schools  in  the  country. 

Although  purulent  ophthalmia  is  undoubtedl}^  propa- 
gated by  inoculation,  yet  there  is  abundant  evidence  to 
show  that  it  may  be  epidemic,  and  spread  without  any  di- 
rect conve3'ance  of  the  purulent  secx'etion  from  e3'e  to  eye. 


22  DISEASES    OP   THE    CONJUNCTIVA. 

I  think  myself  that  the  ordinary  catarrhal  ophthalmia 
may,  and  frequently  does,  assume  a  contagious  form,  and 
that  it  is  liable  to  do  so  whenever  it  attacks  members  of 
a  community  who  are  living  in  violation  of  the  laws  of 
health. 

Treatment. — A  mild  case  of  purulent  ophthalmia  should 
be  treated  in  the  same  way  as  catarrhal  ophthalmia,  page 
13  ;  but  if  the  case  is  severe  the  plan  of  treatment  recom- 
mended for  gonorrhoeal  ophthalmia,  page  23,  should  be 
adopted.  After  the  severit}^  of  the  disease  has  been  ar- 
rested, there  is  apt  to  remain  a  muco-puruleut  discharge, 
which  will  obstiuatel}^  resist  all  treatment  for  many 
weeks,  or  even  months.  Upon  everting  the  lids,  it  will 
be  often  found  that  this  chronic  discharge  is  due  to  a 
granular  condition  of  the  palpebral  conjunctiva  induced 
by  the  disease.  (See  Treatment  of  Granular  Lids, 
page  32.) 

In  all  outbreaks  of  the  disease  sanitarj'^  precautions 
should  be  taken  to  prevent  it  spreading,  and  the  bad  cases 
should  be  kept  apart  from  the  others.  A  daily  inspection 
should  be  also  made  to  treat  each  fresh  case  as  soon  as 
the  earh'^  symptoms  show  themselves. 

Results  of  Purulent  Oplithalmia. — 1st.  If  the  disease 
resists  all  treatment,  the  ej^e  may  be  lost  from  ulceration 
or  sloughing  of  the  cornea.  2d.  The  eyQ  maj^  recover, 
but  w^ith  a  nebula  of  the  cornea,  or  a  leiicoma,  to  the 
inner  surface  of  which  the  iris  is  frequently  attached, 
causing  a  distortion  of  the  pupil.  3d.  A  granular  state 
of  the  lids,  with  a  chronic  muco-purulent  discharge. 

GoNORRHCEAL  OPHTHALMIA  is  au  acutc  spccific  inflam- 
mation of  the  conjunctiva  of  the  lids  and  globe,  induced 
by  the  inoculation  of  some  gonorrheal  matter  into  the 
eye.  It  is  characterized  b}"  a  profuse  purulent  discharge 
from  between  the  lids,  which  is  of  a  yellow  color,  and  ex- 


GONORRHCEAL    OPHTHALMIA.  23 

actly  corresponds  iu  appearance  with  that  which  flows 
from  the  urethra.  The  disease  is  rapid  in  its  progress  and 
very  destructive ;  unless  it  is  soon  checked,  the  eye  is  lost. 
Synijitoms. — Acute  inflammatory  action  usually  com- 
mences in  from  six  to  eighteen  hours  after  the  inoculation 
has  been  efiected.  The  earlj^  symptoms  resemble  those  of 
catarrhal  ophthalmia,  but  they  are  more  severe.  A  slight 
thin  discharge  first  begins  to  ooze  from  between  the  lids, 
accompanied  bj'  a  sense  of  heat  and  fulness  of  the  eye. 
The  conjunctiva  of  the  globe  grows  red,  swollen,  and  che- 
mosed,  often  rising  above  the  level  of  the  cornea,  which 
will  appear  as  if  it  were  partiall}'  buried  below  it.  The 
lids  are  swollen,  red,  and  shining,  and  completely  closed 
over  the  e^^e.  The  discharge  has  now  become  excessive 
in  quantity,  of  a  thick  consistence  and  yellow  color,  and 
streams  over  the  cheeks  from  between  the  lids.  The  cor- 
nea is  almost  certain  to  become  involved ;  and  if  the  in- 
flammation be  not  quickly  subdued,  ulceration  and  slough- 
ing of  its  structure  will  surely  follow.  The  patient  suffers 
severel}^  from  the  pain  in  the  eye  and  around  the  orbit, 
with  an  oppressive  feeling  of  heat  and  fulness  of  the  lids 
and  globe.  The  disease  is  usually  confined  to  the  one  eye. 
When  the  second  becomes  afiected,  it  is  generall}^  on  ac- 
count of  due  precaution  not  having  been  taken  to  shield 
it  from  the  danger  of  inoculation. 

Treatment. — A  few  years  ago  the  treatment  consisted 
in  excessive  bleedings  from  the  arm,  and  in  the  use  of 
strong  depressing  medicines.  Experience  has  shown  the 
error  of  such  proceedings,  and  by  now  adopting  a  directly 
opposite  course,  a  far  larger  proportion  of  cases  recover 
with  good  and  useful  eyes.  In  gonorrhoeal  ophthalmia 
the  treatment  must  be  constitutional  and  local. 

Constitutional  Treatment. — From  the  very  commence- 
ment of  the  attack  the  strength  of  the  patient  must  be 
supix»rted  by  tonics,  diffusible  stimuli,  and  a  liberal  diet. 


24  DISEASES    OF   THE    CONJUNCTIVA. 

The  whole  histoiy  of  gonorrhoeal  ophthalmia  is  of  a  de- 
pressing character.  The  patient,  generally  suffering  from 
gonorrhoea  at  the  time  the  e3e  becomes  inoculated,  is,  from 
the  nature  of  his  complaint  and  the  treatment  adopted  to 
cure  it,  below  the  standard  of  health.  The  disease  itself 
is  also  ver}'  exhausting;  but  the  prospect  of  loss  of  vision, 
with  the  utter  annihilation  of  all  future  prospects,  adds 
to  his  sense  of  loneliness  and  despair.  The  fact  that  the 
patient  is  suffering  from  a  severe  urethral  discharge,  will 
not  forbid  the  free  use  of  tonics  and  stimulants.  The 
danger  of  ulceration  and  sloughing  of  the  cornea  is  in- 
creased in  proportion  as  the  vital  powers  are  depressed. 
Having  therefore  first  acted  freelj'  on  the  bowels  by  a 
moderate  purgative,  quinine,  in  2  gr.  doses,  or  the  min- 
eral acids  with  cinchona  (F.  Gl),  should  be  giA'en  CA'ery 
four  hours.  If  there  is  much  pain  or  irritabilit}',  opium 
should  be  prescribed,  either  in  small  quantities  frequently 
repeated,  or  in  one  full  dose  at  bedtime.  "When  there  is 
heat  of  skin,  with  thirst  and  a  furred  tongue,  an  efferves- 
cing mixture  with  ammonia  (F.  53)  may  be  advantage- 
ously ordered  before  prescribing  the  direct  tonics.  The 
diet  should  be  one  of  meat  or  beef  tea,  with  a  certain 
amount  of  wine  or  brand}",  according  to  the  strength  of 
the  patient. 

Local  Treatment. — The  best  applications  are  nitrate  of 
silver,  lotions  of  alum,  or  of  sulphate  of  zinc  and  alum, 
and  cold. 

1st.  Nitrate  of  Silver. — This  is  best  used  in  the  form  of 
solution,  varj'ing  in  strength  from  gr.  10-gr.  30  ad  aquse 
^  1,  according  to  the  severit}'  of  the  case.  The  lids 
should  be  everted,  and  the  conjunctival  surfaces  painted 
over  with  a  camel-hair  brush  with  the  solution,  which 
should  be  allowed  to  remain  a  few  seconds  so  as  to  whiten 
the  parts,  and  be  then  washed  off  with  a  stream  of  cold 
water  from  an  India-rubber  bottle. 


GONORRHEAL  OPHTHALMIA.  25 

This  should  be  repeated  once  daily ;  and,  in  very  bad 
cases,  a  second  application  may  be  necessary.  For  the 
mode  of  applying  the  solution  of  the  nitrate  of  silver,  see 
TreaTxMent  of  Granular  Lids,  page  32.  When  the  lids 
are  so  swollen  that  they  cannot  be  everted,  two  or  three 
drops  of  a  weaker  solution  of  nitrate  of  silver,  from  gr.  2- 
gr.  10  ad  aquae  §  1,  may  be  dropped  twice  a  day  into  the 
eye,  after  it  has  been  first  cleansed  by  syringing  away  the 
discharge  with  cold  water. 

2d.  Lotions  of  Alum,  or  Alum  and  Sulphate  of  Zinc 
(F.  38,  40),  should  be  used  at  least  once  every  hour,  to 
wash  away  the  discharge  as  often  as  it  accumulates.  The 
lotion  should  be  gently  injected  over  the  surface  of  the 
globe  by  a  syringe  or  India-rubber  bottle,  so  as  to  thor- 
oughly wash  away  all  purulent  matter  at  each  applica- 
tion. 

3d.  Cold  is  very  grateful  to  the  patient,  and  may  be 
applied,  during  the  intervals  between  using  the  lotion,  by 
placing  a  fold  of  lint  wet  with  iced  water  over  the  ej^elids 
and  changing  it  as  often  as  it  becomes  hot  or  dry.  The 
patient  may  als6  be  allowed  to  wash  away  the  discharge 
with  a  piece  of  linen  dipped  in  the  iced  water  as  fast  as  it 
exudes  from  between  the  lids. 

By  a  steady  perseverance  in  this  line  of  treatment,  the 
best  chance  of  saving  the  eye  is  afforded  to  the  patient ; 
but  the  disease  is  frequently  of  so  virulent  a  character, 
that,  in  spite  of  all  remedies  and  the  most  judicious  man- 
agement, the  cornea  sloughs,  and  the  eye  for  all  useful 
purposes  is  irretrievably  lost. 

There  is  a  form  of  gonorrhoeal  ophthalmia  consequent 
on  the  virethral  discharge,  but  which  is  not  produced  by 
inoculation.  The  two  eyes  are  affected  simultaneously 
within  a  few  days  or  a  week  after  the  appearance  of  the 
gonorrhoea.  It  closely  resembles  a  very  severe  attack  of 
catarrhal  ophthalmia.     I  have  had  one  gentleman  under 

8 


26  DISEASES    OF   THE   CONJUNCTIVA. 

m}'  care  who  has  had  three  attacks  of  this  form  of  inflam- 
mation of  the  eyes,  coming  on  each  time  shortly  after  he 
had  contracted  a  fresh  gonorrhoea.  The  purulent  dis- 
charge from  the  eyes  was  at  one  time  so  copious  that  I 
thought  it  must  have  been  caused  by  inoculation,  but  its 
reappearance  in  both  eyes  with  each  recurrence  of  the 
urethral  discharge  has  now  convinced  me  that  it  was  due 
to  other  causes.  I  should  add  that  this  patient,  with  each 
attack  of  gonorrhoea,  suffered  severely  from  gonorrhoeal 
rheumatism.  It  is  possible  that  this  form  of  ophthalmia 
may  be  due  to  the  same  absorption  of  the  poison  as  that 
which  induced  the  rheumatism,  and  that  the  discharge 
from  the  ejes  is  an  attempt  to  eliminate  it  through  the 
mucous  surfaces  of  the  globe  and  lids.  Another  explana- 
tion is,  that  in  some  people  there  exists  a  peculiar  sym- 
pathy between  the  mucous  membranes  of  one  part  of  the 
bod}^  with  those  of  another ;  thus,  it  is  not  vmcommon  to 
find  in  common  catarrh  the  whole  mucous  lining  of  the 
body  more  or  less  aflected  at  one  time  ;  and  in  one  gen- 
tleman with  whom  I  am  acquainted  a  severe  catarrhal  at- 
tack is  frequentl}^  accompanied  by  a  discharge  from  the 
urethra. 

Treatment. — The  same  as  for  the  gonorrhoeal  ophthal- 
mia caused  by  inoculation ;  but  as  the  symptoms  are  less 
severe,  so  the  strength  of  the  remedial  applications  to  the 
eye  may  be  reduced.  The  patient  should  be  prescribed  a 
good  nutritious  diet,  with  a  moderate  allowance  of  stimu- 
lants. 

Diphtheritic  Ophthalmia  is  a  disease  which  is  almost 
unknown  in  England.  It  was  first  described  b}'  Y.  Graefe,* 
who  has  witnessed  several  epidemics  of  this  peculiar  affec- 
tion. 

*  Archiv.  f.  Opbthal.  p.  1G8.     1854-5. 


DIPHTHERITIC    OPHTHALMIA.  27 

Sym2:)toms. — The  disease  usually  commences  suddenly 
in  the  upper  eyelids,  which  become  red,  swollen,  and  rigid 
from  fibrinous  effusion  into  the  subcutaneous  tissues. 
The  conjunctiva  of  the  lid  is  found,  on  eversion,  to  be 
smooth,  dry,  and  pale  from  constriction  of  the  palpebral 
vessels.  The  lower  lid  then  becomes  similarly  affected, 
and  the  conjunctiva  of  the  globe  chemosed,  not,  as  in  ca- 
tarrhal ophthalmia,  from  serous  effusion,  but  from  exuda- 
tion of  fibrin.  As  the  disease  advances,  the  swelling  and 
redness  of  the  lids  increase ;  there  is  great  pain  and  heat, 
and  a  thin  discharge  with  flocculi  of  13'mph  oozes  from  the 
eye.  This,  after  a  few  days,  becomes  purulent,  and  the 
rigidity  of  the  lids  begins  to  subside.  During  the  prog- 
ress of  the  disease,  fibrinous  exudations  will  occasionally 
take  place  on  the  conjunctival  surfaces  of  the  lids  and 
globe,  either  as-  small  isolated  gray  patches,  or  else  as  a 
continuous  membrane,  which  may  be  peeled  off.  The 
cornea  is  speciall}'-  apt  to  suffer  in  this  disease.  It  first 
becomes  hazy,  portions  of  its  epithelium  are  then  de- 
tached, and  an  ulcer  is  formed,  which  nia}^  lead  to  perfo- 
ration and  prolapse  of  the  iris,  or  parts  of  the  cornea  may 
slough.  During  the  process  of  repair,  which  afterwards 
follows,  the  fibrinous  exudations  on  the  lining  membrane 
of  the  lids  are  thrown  off,  and  the  conjunctiva  appears 
almost  bared  of  its  epitheUum.  Cicatrization  and  con- 
traction now  set  in,  and  not  unfrequently  cause  some  in- 
version or  eversion  of  the  lid. 

Treatment. — At  the  commencement  of  the  disease.  Yon 
Graefe  recommends  a  strictly  antiphlogistic  treatment ; 
and  if  the  health  of  the  patient  admits  of  it,  he  places 
him  quickly  under  the  influence  of  mercurj^  As  local  ap- 
j^lications,  he  relies  chiefly  upon  iced  compresses  to  the 
eye  and  leeches  to  the  temple,  the  latter  being  frequently 
used  in  large  numbers. 

In  the  second  stage,  when  there  is  a  purulent  discharge, 


28  DISEASES    OF   THE    CONJUNCTIVA. 

he  advises  the  conjunctival  surfaces  of  the  lids  to  be 
touched  with  the  solid  mitigated  nitrate  of  silver  (F.  5, 
No.  2);  or,  if  j^referred,  they  may  be  painted  with  a  solu- 
tion of  the  strength  of  gr.  10-gr.  20  ad  aquffi  ^  1. 

After  the  nitrate  of  sih'er  has  been  applied,  either  by 
stick  or  in  solution,  thirty  or  forty  seconds  should  be  al- 
lowed to  elapse,  and  then  a  stream  of  cold  water,  or  weak 
salt  and  water,  should  be  directed  over  the  parts,  to  wash 
away  any  surplus  of  the  drug  which  ma}'  remain,  and 
prevent  its  affecting  injuriously  the  cornea.  When  the 
lids  cannot  be  everted,  either  on  account  of  the  swelling 
or  pain,  a  solution  of  the  nitrate  of  silver,  gr.  1 — gr.  5  ad 
aquae  ^  1,  may  be  dropped  twice  daily  into  the  eyes ;  or 
they  may  be  washed  out  with  an  astringent  lotion  (F.  39, 
40)  thrown  beneath  the  lids  by  means  of  a  syringe. 

Granular  Lids — Granular  Ophthalmia;   Trachoma; 

Granulations These  terms  have  been  applied  to  a  rough 

and  granular  state  of  the  lids,  which  induces  a  chronic 
muco-purulent  discharge  from  the  conjunctiva,  and  pan- 
nus  of  the  cornea.  Granulations  are  usually  the  result  of 
purulent  or  contagious  0])hthalmia,  or  of  some  long-cou- 
tinued  conjunctival  inflammation.  There  is,  however,  one 
form  of  granular  lids  produced  by  vesicular  granulations, 
which  may  originate  without  an}-  previous  severe  or  pro- 
longed aflection  of  the  conjunctiva. 

Granulations  ma}'  be  divided  into  two  classes — the  true 
and  the  vesicular. 

The  true  granulations  are  those  which  arise  from  puru- 
lent ophthalmia,  or  from  any  chronic  irritation  of  the  con- 
junctiva. The  inner  surfaces  of  the  lids  lose  their  bright 
polish  and  smoothness,  and  become  rough  from  the  growth 
of  numerous  small  vascular  projections.  These  granula- 
tions are  ^tartly  produced  by  an  hypertrophy  of  the 
papillae  of  the  lids,  but  partly  also  by  an  inflammatory 


GRANULAR    LIDS.  29 

exudation  into  the  connective  tissue  of  the  conjunctiva, 
to  which  is  principall}'  clue  the  subsequent  cicatricial 
changes.  During  the  earl}^  stages  the  granulations  are 
red,  highly  vascular,  and  l)leed  easily  on  being  pressed  or 
rubbed  with  the  finger.  The  mere  effort  of  everting  the 
lids,  which  are  usuall}^  somewhat  thickened,  is  sufficient 
to  make  them  bleed.  In  the  later  stages  the  granulations 
become  paler  and  fewer  in  number,  and  the  conjunctiva 
between  them  grows  anjemic  and  shrunken,  with  a  bright 
tendinous  lustre  like  cicatricial  tissue.  At  the  commence- 
ment of  the  disease  there  is  fulness  and  hyperemia  of  the 
palpebral  conjunctiva,  whilst  at  its  termination  there  is 
anaemia  and  consolidation.  The  appearances  of  the  gran- 
idations  vary  considerably,  according  to  the  severity  of 
the  inflammation  which  produced  them,  the  stage  at  which 
they  have  arrived,  and  the  treatment  to  which  they  have 
been  subjected.  In  some  cases  the  palpebral  conjunctiva 
is  coA'ered  with  small,  red,  villous-looking  granulations  of 
a  nearly  uniform  size ;  in  others,  with  red  granulations 
varying  in  size  and  shape ;  whilst  frequently  the  granula- 
tions are  pale,  flabb}",  and  scattered,  with  the  spaces  be- 
tween them  apparent!}'  occupied  by  cicatricial  tissue. 

Vesicular  Gi-anulations. — These  appear  as  small,  round, 
whitish  bodies,  scattered  on  the  conjunctiva  of  both  the 
upper  and  lower  ej'clids,  slightl}'^  projecting  from  the  sur- 
face, and  usualty  in  the  greatest  numbers  about  the  oculo- 
palpebral  fold  of  the  upper  lid.  They  have  been  likened 
to  boiled  sago-grains,  or  to  frog's  spawn,  or  to  the  vesi- 
cles of  an  herpetic  eruption.  They  look  as  if  the}^  con- 
tained a  little  semi-transparent  fluid,  but  the}'  are  solid 
growths,  and  so  firml}^  implanted  that  it  is  very  difficult 
to  remove  them,  as  when  punctured  they  will  not  easily 
shell  out  from  the  subconjunctival  tissue  in  which  thej'^ 
are  imbedded.  The}^  are  met  with  both  in  children  and 
adults,  but  they  are  most  liable  to  occur  amongst  masses 

3* 


30  DISEASES    OF    THE    CONJUNCTIVA. 

of  people  who  live  iu  a  crowded  atmosphere,  with  neglect 
of  all  sanitary  arrangements.  Hence  it  is  that  they  are 
so  frequently  seen  amongst  the  children  in  workhouses, 
the  poor  Irish  in  large  towns,  and  amongst  soldiers  in 
baiTacks.  Vesicular  granulations  are  contagious,  and 
due  to  malarious  influences  ;  and,  from  the  constant  irri- 
tation they  keep  up,  are  very  apt  to  lead  to  the  formation 
of  the  true  conjunctival  granulations.  They  may  exist 
for  some  time  without  giving  any  greater  anno3-ance  than 
a  slight  sense  of  pricking,  and  a  little  stickiness  about 
the  lids  in  the  morning.  In  most  cases,  however,  there 
is  lachrymation,  with  a  constant  feeling  of  grittiness  of 
the  eye,  and  a  slight  muco-purulent  discharge ;  and  if  the 
disease  is  advanced,  a  nebulous  and  vascular  condition  of 
that  portion  of  the  cornea  which  is  subjected  to  the  fric- 
tion of  the  upper  lid  over  it.  The  severity  of  the  symp- 
toms vary,  but  they  are  always  increased  by  exposure  to 
glare  or  to  cold  winds. 

Symptoms. — A  feeling  of  constant  grittiness  and  a 
sense  of  heat  in  the  eye,  with  some  photophobia,  and  a 
muco-purulent  discharge  suflicient  to  cause  the  lids  to 
gum  together  in  the  morning.  There  is  redness  of  the 
caruncle  and  tarsal  margins,  and  in  advanced  cases  the 
upper  lid  droops  as  if  it  hung  heavily  over  the  eye.  As 
the  disease  progresses,  the  cornea  suflers  from  the  con- 
stant friction  of  the  roughened  palpebral  conjunctiva.'  It 
becomes  vascular  and  nebulous,  its  surface  grows  uneven, 
and  at  points  frequently  ulcerates.  This  vascular  con- 
dition of  the  cornea,  dependent  on  granulations,  has  been 
termed  "  trachomatous  j^ojinus,^^  to  distinguish  it  from 
that  pannus  which  is  the  result  of  corneitis  induced  from 
other  causes.  In  some  cases  the  pannus  is  confined  to 
the  upper  half  of  the  cornea,  the  part  which  is  under  the 
cover,  and,  consequently,  subjected  to  the  friction  of  the 
tipper  lid ;  but  in  granulations  of  long  standing,  the  whole 


GRANULAR    LIDS.  31 

surface  of  the  cornea  becomes  vascular,  every  portion  of 
it  being  pervaded  with  bloodvessels.  All  these  symptoms 
are  greatly  increased  if  the  eyes  are  overworked,  or  ex- 
posed to  cold  winds  or  bright  lights.  Occasionally  the 
eyes  will  become  acutely  inflamed,  constituting  the  con- 
dition described  as  Acute  Granidai"  Ojjhthalmia;  the  lids 
are  then  red,  swollen,  and  spasmodically  closed  from  the 
excessive  photophobia,  and  any  attempt  to  open  them  is 
foUow^ed  by  a  gush  of  hot  tears,  with  some  muco-purulent 
discharge.  Under  treatment,  these  acute  symptoms  will 
gradually  subside,  and  the  eyes  will  again  relapse  into 
their  previous  state  of  chronic  irritability. 

Prognosis Judicious  management,  coupled  with  the 

reparative  power  of  time,  will  generally  succeed  in  oblit- 
erating the  granulations  and  restoring  a  smooth  surface 
to  the  palpebral  conjunctiva.  If  the  disease  has  been 
slight,  or  of  only  short  duration,  there  is  good  reason  to 
hope  that  the  eye  will  so  recover  from  the  irritation  to 
which  it  has  been  subjected,  that  it  will  regain  the  greater 
part,  if  not  the  whole,  of  the  sight  it  had  lost.  If,  how- 
ever, the  granulations  have  been  severe  and  long-con- 
tinued, they  will  probably  have  i^roduced  mischief  which 
neither  time  nor  remedies  will  ever  completelj'^  eradicate. 
The  conjunctiva  will  frequently  become  changed,  both  in 
appearance  and  structure.  Although  its  surface  may 
have  grown  smooth,  yet  it  will  be  more  contracted  and 
dense  than  formerly,  and  have  acquired  in  different  parts 
a  whitish,  glistening  aspect,  closely  resembling  cicatricial 
tissue.  This  contraction  of  the  palpebral  conjunctiva  is 
the  most  frequent  cause  of  entropion  and  distichiasis. 
(See  articles  on  each  of  these  subjects.) 

The  cornea,  from  the  constant  friction  of  the  rough- 
ened lids  against  it,  will  often  become  so  uneven,  vascu- 
lar, and  cloud^',  that  for  all  useful  purposes  the  eye  will 
be  practically  blind. 


32  DISEASES    OF   THE    CONJUNCTIVA. 

Treatment. — The  object  to  be  accomi^lislied  is  to  re- 
store a  smooth  surface  to  the  lining  membrane  of  the  lids 
by  the  obliteration  of  the  granulations  ;  but  in  endeavor- 
ing to  gain  this  end,  care  must  be  taken  to  avoid  the  use 
of  all  strong  remedies  which  will  destro}'  the  conjunctiva, 
and  produce  deep  cicatrices.  The  treatment  from  which 
I  have  found  the  greatest  benefit  has  been  the  application 
to  the  palpebral  conjunctiva  of  a  strong  solution  of  the 
nitrate  of  silver,  var3dng  in  strength  according  to  the 
severity  of  the  case,  from  gr.  5 — gr.  20  ad  aquse  |  1.  This 
should  be  applied  in  the  following  manner :  The  patient 
is  to  be  seated  in  a  chair,  and  the  surgeon,  standing  be- 
hind him,  with  a  probe  everts  the  upper  lid  so  as  fully  to 
expose  the  palpebral  conjunctiva,  over  the  surface  of 
which  he  paints,  Avith  a  camel's-hair  brush,  the  solution  of 
the  nitrate  of  silver,  taking  care  to  appl}'  it  thoroughly  to 
the  reflection  of  conjunctiva  which  forms  the  oculo-palpe- 
bral  fold.  After  waiting  for  about  half  a  minute,  he  then, 
with  a  syringe,  gently  squirts  over  the  granular  surface  a 
stream  of  cold  water,  or,  what  is  better,  a  solution  of  com- 
mon salt  of  about  the  strength  of  gr.  10  ad  aquie  5  1,  to 
wash  away  and  neutralize  all  the  surplus  nitrate  of  silver, 
so  as  to  prevent  its  irritating  the  eye,  or  blackening  the 
ocular  conjunctiva, — a  misfortune  I  have  seen  occur  when 
strong  solutions  of  the  caustic  have  been  frequentl3'  used 
without  taking  these  precautions.  This  application  should 
be  repeated  every  second  or  third  day,  and  in  the  inter- 
vals the  patient  should  frequently-  bathe  the  ca'cs  with 
cold  water,  and  every  night  and  morning  drop  into  them 
a  little  of  a  weak  solution  of  the  chloride  of  zinc  (F.  19), 
or  some  other  mild  astringent.  The  nitrate  of  silver  ma}' 
be  also  conveuientl}-  applied  to  the  granulations  by  using 
the  diluted  nitrate  of  silver  points  (F.  5). 

Suljiihafe  of  Cojyjier,  or  a  combination  of  this  salt  with 
alum,   "  lapis  divinus,"  or  "  greenstone,"  as  it  is  com- 


GRANULAR    LIDS.  33 

raonly  called  (F.  4),  are  excellent  astringents  in  granular 
lids.  Every  second  or  third  day  the  lid  should  be  everted, 
and  having  first  dried  the  surface  with  a  piece  of  linen, 
the  granulations  only  should  be  freely  touched  with  the 
sulphate  of  copper  or  greenstone,  taking  as  much  care 
as  possible  to  prevent  the  caustic  from  affecting  the  con- 
junctiva. Between  the  applications  a  few  drops  of  the 
guttfe  cupri  sulphatis  (F.  21)  should  be  dropped  twice  a 
day  into  the  eye. 

Acetate  of  Lead  is  a  useful  remedy  when  there  is  ex- 
cessive roughness  from  the  whole  palpebral  conjunctiva 
being  covered  with  red  granulations  of  varying  sizes,  but 
unattended  by  any  acute  inflammatory  symptoms.  The 
acetate  of  lead  should  be  finel}^  powdered  and  laid  over 
the  granulations,  and,  after  waiting  one  or  two  minutes, 
the  surplus  should  be  washed  off  with  a  stream  of  cold 
water.  This  application  does  good,  first,  b}'  rendering 
the  surface  more  smooth  by  filling  up  the  chinks  between 
the  granulations,  and  afterwards  hy  its  astringent  powers 
causing  them  to  shrink.  It  may  be  repeated  three  or  four 
times,  at  intervals  of  from  three  to  six  days. 

Liquor  Potassee. — Mr.  Dixon  speaks  very  highl}'  of  the 
benefit  to  be  derived  from  the  local  application  of  liq. 
potassae  to  the  granulations.  He  says :  "  The  fluid  is 
dabbed  upon  the  everted  lids,  so  as  to  be  thoroughly 
brought  into  contact  with  the  whole  surface."  And  fur- 
ther on  he  remarks:  "It  may  be  applied  at  intervals  of  a 
few  days ;  and  in  some  cases  I  have  seen  the  granulations 
removed,  and  much  of  the  original  clearness  of  the  coi:nea 
restored,  in  the  course  of  six  weeks."* 

When  there  are  severe  inflammatory  sjTnptoms,  as  in 
"  acute  granular  ophthalmia,"  it  is  best  to  postpone  the 
use  of  astringents  until  they  have  partiall}"  subsided.    In 

*  Dixon  on  Diseases  of  the  Eye,  third  edition,  p.  56. 


34  DISEASES    OF    THE    CONJUNCTIVA. 

sTich  cases  great  relief  is  often  derived  from  applying  a 
slight  compress  and  bandage  (F.  2)  over  the  closed  lids, 
and  onl}^  removing  it  for  the  purpose  of  bathing  the  eyes 
three  or  four  times  during  the  twenty-four  hours  with  the 
lotio  belladonnse  (F.  32),  or  the  lotio  belladonnas  cum 
alumine  (F.  33).  If,  however,  as  sometimes  happens,  the 
compressing  bandage  should  ])rove  hot  and  uncomfort- 
able, it  should  be  given  up,  and  in  its  place  a  fold  of  lint 
wet  with  the  lotio  belladonna  cum  alumine  (F.  33)  should 
be  suspended  over  the  eye  by  a  piece  of  broad  tape  tied 
round  the  forehead.  As  soon  as  the  swelling  and  redness 
of  the  lids  have  sufficiently  abated  to  allow  of  their  being 
everted  without  much  pain,  a  weak  solution  of  the  nitrate 
of  silver  should  be  painted  once  daily  over  the  palpebral 
conjunctiva,  and  in  the  intervals  between  the  applications 
the  belladonna  lotion  may  be  continued.  Even  in  cases 
of  granular  lids,  where  there  are  no  severe  inflammatory 
s^'mptoms,  but  where  the  photophobia  and  lachr3-mation 
are  excessive,  I  have  often  found  benefit  from  the  use  of 
the  compressing  bandage,  as  by  it  the  eye  is  kept  com- 
pletely at  rest,  and  the  friction  between  the  lids  and  the 
cornea  is  prevented. 

Inocidation  wdth  purulent  matter  for  the  cure  of  severe 
granular  lids  is  a  most  successful  mode  of  treatment.  It 
requires,  however,  great  caution  in  the  selection  of  cases 
fitted  for  this  procedure,  and  also  in  the  choice  of  the  pus 
with  which  to  inoculate  the  eyes.  The  whole,  or  certainly 
two-thirds,  of  the  cornea  should  be  so  permeated  with 
vessels  as  to  render  it  semi-opaque,  as  the  purulent  oph- 
thalmia established  bj'^  the  inoculation  is  xevy  liable  to  in- 
duce sloughing  in  anj^  portion  of  it  which  is  quite  trans- 
parent. The  pus  should  be  chosen  from  the  e3'e  of  an 
infant  suflTering  from  purulent  ophthalmia.  Its  strength 
may  be  determined,  firstly,  l)y  the  color,  and,  secondly, 
by  the  severity  and  duration  of  the  inflammation  it  has 


GRANULAR    LIDS.  35 

excited  iu  the  eye  from  which  it  is  takeu.  The  yellow 
pus  is  always  more  active  than  the  whitish  discharge  seen 
in  slight  cases  of  purulent  ophthalmia.  The  period  of  the 
disease  at  which  the  pus  is  taken  influences  materially 
the  amount  of  inflammation  and  suppuration  it  is  capable 
of  setting  up.  Pus  from  the  eye  of  an  infant  in  the  early 
and  most  acute  stage  of  purulent  ophthalmia  will  produce 
more  serious  effects  than  that  taken  from  the  same  eye  at 
a  later  period  of  the  disease,  after  it  has  undergone  some 
treatment  and  is  on  the  decline.  If  one  e3'e  only  is  to  be 
inoculated,  the  other  should  be  tied  up  so  as  to  protect  it 
from  contagion.  Mr.  Bader,  who  has  had  great  experi- 
ence in  inoculation  for  granular  lids,  advises  that  a  la^er 
of  Canada  balsam  or  gum  mastic  should  be  spread  over 
the  skin  of  the  closed  eyelid  and  adjacent  side  of  the 
nose,  and  upon  this  should  be  placed  sutficient  wadding 
to  fill  up  the  hollow  to  a  level  with  the  bridge  of  the  nose, 
and  over  the  whole  a  single  turn  of  a  light  bandage 
should  be  fastened.*  Great  care  and  cleanliness  will  be 
required  during  the  whole  of  the  treatment  to  prevent 
the  other  eye  from  becoming  infected ;  the  bandage 
should  be  changed  dail}",  and  readjusted  as  often  as  it 
becomes  loose. 

To  inoculate  the  eye,  a  single  drop  of  pus  should  be 
taken  with  a  small  scoop,  or  the  end  of  the  little  finger, 
from  the  eye  of  an  infant  with  purulent  ophthalmia,  and 
placed  on  the  conjunctiva  of  the  lower  lid.  In  from  eight 
to  twentj^-four  hours  the  first  symptoms  of  purulent  oph- 
thalmia will  begin  to  show  themselves,  and  will  rapidly 
increase  until  the  disease  has  reached  its  height.  The  ac- 
tivity of  the  inflammation  usually  lasts  from  eight  to  ten 
days,  but  the  discharge  will  not  completely  abate  for  six 

*  Bader  on  the  Natural  and  Morbid  Changes  of  the  Iluman 
Eye,  p.  115. 


36  DISEASES    OF   TUE    CONJUNCTIVA. 

or  eight  weeks.  As  soon  as  the  discharge  becomes  pro- 
fuse, the  patient  should  be  allowed  to  wash  the  eyes  with 
cold  water  every  hour,  or  even  oftener  if  he  desires  it, 
and  if  there  is  much  pain  he  may  use  iced-water,  and 
when  lying  down  keep  a  fold  of  lint  wetted  with  it  over 
the  eyelids.  No  astringent  application  should  be  given 
to  check  the  discharge,  but  the  disease  must  be  allowed 
to  run  its  course  uninterruptedly.  The  danger  to  be  ap- 
prehended is  sloughing,  or  ulceration  of  a  portion  of  the 
cornea.  During  the  progress  of  the  inflammation  it  is 
often  very  difficult  to  decide  whether  the  cornea  is  still 
entire,  as  from  its  red  and  swollen  A'illous  appearance  it 
is  difficult  to  even  distinguish  it  from  the  surrounding 
vascular  conjunctiva.  The  only  test,  then,  is  to  notice  its 
curvature  ;  and,  if  this  remains  unchanged,  and  there  is 
no  depression  in  one  part  with  a  lump  of  swollen  granu- 
lations in  another,  no  anxiety  need  be  felt.  The  patient 
should  be  allowed  a  liberal  meat  diet,  with  a  fair  amount 
of  stimulants,  during  the  whole  period  of  treatment.  If 
his  appetite  or  strength  fail,  quinine  or  bark  (F.  61,  64) 
should  be  prescribed ;  and  if  from  the  pain  his  nights  are 
disturbed,  opiates  may  be  given  at  bedtime.  It  should  be 
remembered,  that  although  inoculation  will  obliterate  the 
granulations  from  the  lids,  and  the  vessels  from  the  cor- 
nea, yet  it  will  not  efface  previously  existing  nebulosities. 
Some  operation  is  often  afterwards  required  to  alter  the 
shape  of  the  pupil,  so  as  to  bring  it  opposite  that  por- 
tion of  the  cornea  which  is  most  transparent.  The  re- 
sults of  my  experience  of  inoculation  in  severe  cases  of 
granulai"  lids  have  been  most  brilliant.  I  have  seen  pa- 
tients practically  blind  for  years,  and  condemned  to  the 
workhouse,  regain  sufficient  sight  to  resume  their  former 
occupations. 

Syndectomy  —  Peritomy This   operation   was   first 


SYNDECTOMY.  37 

practised  b}'  Dr.  Furnari,  of  Paris,  in  1862.*  It  consists 
in  excising  a  band  of  conjunctiva  and  subconjunctival 
tissue  of  about  one-eighth  of  an  inch  in  width  from 
around  the  cornea  and  close  up  to  its  margin.  It  may  be 
performed  in  the  following  manner:  The  patient  being 
placed  under  chloroform,  and  the  lids  widely  separated 
with  a  spring  speculum,  a  fold  of  conjunctiva  is  to  be 
seized  with  a  pair  of  finely-toothed  forceps,  and  with  a 
pair  of  blunt-pointed  curved  scissors  an  incision  is  to  be 
carried  through  that  membrane  around  the  cornea,  and 
at  about  one-eighth  of  an  inch  distant  from  it.  The  band 
of  conjunctiva  surrounding  the  cornea  is  now  to  be  dis- 
sected off,  and  all  the  subconjunctival  tissue  and  vessels 
between  it  and  the  sclerotic  care  full}'  removed  close  up 
to  the  corneal  margin.  The  operation  being  now  com- 
pleted, the  lids  are  to  be  closed  and  covered  with  a  wet 
compress  and  a  bandage. 

Dr.  Furnari  recommends  that  after  the  excision  of  the 
band  of  conjunctiva  and  submucous  tissue,  the  exposed 
surface  should  be  freely  touched  with  the  nitrate  of  silver; 
but  this  is  a  most  daugerous  proceeding,  and  in  the  few 
cases  in  which  it  has  been  tried  in  this  country,  has  pro- 
duced very  prejudicial  results.  After  three  or  four  days, 
the  wound  will  be  found  covered  with  lymph,  and  in  a 
few  weeks  it  will  be  perfectly  closed,  partl}^  from  contrac- 
tion of  the  surrounding  conjunctiva,  but  partly  also  by 
the  formation  of  a  smooth  cicatrix  tissue.  This  operation 
is  well  suited  for  severe  cases  of  pannus  which  continue 
after  the  granulations  of  the  lids  have  been  obliterated ; 
but  my  experience  of  it,  for  the  cure  of  granulations,  is 
that  it  is  unsuccessful.  I  have,  on  several  occasions,  per- 
formed syndectomy  as  a  preliminary  to  inoculation,  and 
allowed  the  eye  to  recover  from  all  effects  of  the  opera- 

*  Gazette  Medicale,  Nos.  4-6,  8,  &c.,  18G2. 
4 


38  DISEASES    OF    THE    CONJUNCTIVA. 

tion  before  introducing  the  pns.  The  virulence  of  the 
purulent  ophthalmia  seemed  to  have  been  materially  di- 
minished by  the  removal  of  the  portion  of  conjunctiva, 
and  by  the  broad  cicatrix  which  it  had  produced  around 
the  cornea.  For  a  detailed  account  of  these  cases,  see 
"Roj^al  London  Ophthalmic  Hospital  Reports,"  vol.  iv, 
page  182. 

Pterygium  is  a  peculiar  morbid  growth  of  the  conjunc- 
tiva and  subconjunctival  tissue.  It  is  of  a  triangular 
shape,  with  its  base  usually  at  the  semilunar  fold  close  to 
the  inner  canthus,  and  extending  outwards  it  gradually 
tapers  to  a  rounded  end  w^hich  is  implanted  on  the  sur- 
face of  the  cornea,  generally  reaching  to  a  point  oj^posite 
the  inner  margin  of  the  pupil,  and  sometimes  spreading 
halfway  across  it.  I  have  never  seen  the  pupil  com- 
pletely occluded  by  the  growth.  A  pterj-gium  is  more 
or  less  vascular,  and  one  or  two  large  conjunctival  ves- 
sels may  be  frequently  seen  coursing  along  it.  In  some 
cases  it  is  red,  fleshy,  and  prominent,  whilst  in  others  it 
is  pale  and  membranous,  and  so  thin  as  to  be  almost 
translucent. 

A  pterygium  is  almost  invariably  a  single  growth  con- 
fined to  the  inner  half  of  the  eye,  although  to  this  there 
are  occasional  exceptions,  and  cases  have  been  reported 
where  there  have  been  two  pter3'gia,  one  on  each  side  of 
the  cornea,  and  also  where  the}'  have  occurred  in  the  up- 
per and  lower  parts  of  the  eye,  in  lines  corresponding 
with  the  superior  and  inferior  recti  muscles.  The  disease 
may  be  limited  to  one  e3'e,  or  both  may  be  affected  by  it. 
I  have  seen  man}^  cases  in  which  a  pterj^gium  existed  in 
both  eyes ;  in  all  of  them  the  growths  were  symmetrical. 
Patients  about  the  middle  age  are  most  liable  to  ptery- 
gium, and  especially  those  who  have  served  long  in  trop- 
ical climates.     It  is  seldom  seen  in  the  young.     The  dis- 


PTERYGIUM.  89 

ease  is  of  slow  and  almost  imperceptible  growth,  and  it 
is  not  until  it  lias  attained  a  considerable  size  that  it 
causes  any  annoj-ance.  When  it  extends  partially  over 
the  pupil  it  interferes  with  vision. 

Treatment.  —  There  are  only  two  ways  of  efficiently 
dealing  with  a  pterygium.  It  may  be  excised,  or  its 
apex  may  be  transplanted  from  the  cornea  to  a  part  of 
the  conjunctiva,  where,  even  if  it  were  to  grow,  it  would 
cause  no  impairment  of  vision.  No  local  application  to 
the  eye  will  be  of  any  benefit  in  eradicating  the  disease. 

1.  Excision  of  the  Pterygium. — The  lids  being  sepa- 
rated by  a  spring  speculum,  the  pterygium  is  to  be  seized 
from  above  downwards  by  a  pair  of  forceps  and  drawn 
slightly  from  the  eye.  With  a  pair  of  fine  scissors  or  a 
Beer's  knife,  its  attachment  to  the  cornea  is  to  be  sepa- 
rated, and  then,  with  a  few  snips  of  the  scissors,  the 
greater  part  of  the  pterygium,  or  the  whole  of  it,  if  it  be 
small,  is  removed. 

If  the  base  of  the  growth  is  large,  no  attempt  should 
be  made  to  excise  the  whole  of  it,  as  the  too  free  removal 
of  the  conjunctiva  will  cause  a  tight  cicatrix,  which  will 
greatly  impair  the  outward  movements  of  the  eye.  After 
the  pterygium  has  been  removed,  the  cut  edges  of  the 
conjunctiva  should,  if  the  gap  is  not  too  wide,  be  drawn 
together  with  one  or  two  fine  sutures. 

2.  Transplantation  of  the  Pterygium. — This  operation 
was  first  suggested  and  practised  by  Desmarres.  I  have 
tried  it  myself  on  many  occasions,  and  have  been  well 
satisfied  with  the  results.  The  operation  may  be  per- 
formed as  follows :  The  lids  having  been  separated  by  the 
spring  speculum,  the  extremity  of  the  pterygium  is  to  be 
seized  with  a  pair  of  forcejis  close  to  the  cornea,  and  its 
union  with  that  structure  carefully  parted  by  a  few  snips 
with  a  pair  of  fine  scissors.  One  cut  is  then  to  be  made 
with  the  scissors  through  the  conjunctiva  along  the  upper. 


40  DISEASES    OF   THE    CONJUNCTIVA. 

and  another  along  the  lower  border  of  the  pterj-gium. 
At  the  point  of  the  lower  free  cut  edge  of  the  conjunc- 
tiva, to  which  it  is  desired  to  plant  the  apex  of  the  growth, 
a  smaU  nick  is  to  be  made  with  the  scissors,  and  into  this 
the  cone  of  the  pterj^gium  is  to  be  fixed  by  a  single  fine 
thread  suture. 

The  pterygium,  now  separated  completely  from  the 
cornea  and  implanted  into  the  conjunctiva,  generally 
wastes,  and  becomes  so  shrunken  that  it  ceases  to  draw 
attention  to  the  e^^e.  Such  has  been  the  result  in  the 
cases  in  which  I  have  performed  this  operation.  The 
great  advantage  which  transplantation  offers  over  excis- 
ion of  the  pterygium  is,  that  as  there  is  no  removal  of  a 
portion  of  the  conjunctiva,  there  is  afterwards  no  dense 
cicatrix  to  cause  a  drawing  in  of  the  eye,  or  to  limit  its 
movements  outwards. 

Pinguecula  is  a  term  applied  to  a  small  j-ellowish 
patch  which  is  frequently  seen  on  the  eye  near  the  mar- 
gin of  the  cornea,  and  is  apparently  in  the  substance  of 
the  conjunctiva.  In  a  specimen  examined  by  Desmarres, 
the  growth  was  found  to  be  composed  exclusively  of 
h^^pertrophied  conjunctival  epithelium.  It  creates  annoy- 
ance sometimes  from  its  being  a  little  conspicuous,  but 
it  is  perfectly  innocuous.  If  its  presence  worries  the 
patient,  it  may  be  removed  b}^  seizing  hold  of  it  with 
forceps,  and  snipping  it  off  with  a  pair  of  fine  scissors. 

Dermoid  Tumors  generally  spring  from  the  margin 
of  the  cornea  and  the  adjacent  sclerotic.  The}-  are  usu- 
all}^  smooth,  light-colored  growths,  covered  with  con- 
junctiva and  with  a  few  hairs  sprouting  from  their  sur- 
face. They  are  congenital,  and  consist  of  elastic  and  con- 
nective tissue  and  fat. 

Treatment. — The  only  waj'  to  get  rid  of  these  tumors 


ECCIIYMOSIS.  41 

is  by  excision.  Whilst  operating,  care  must  be  taken 
not  to  dissect  deeply  into  the  sclerotic  and  cornea,  even 
though  the  origin  of  the  tumor  should  apparently  be  be- 
low their  surfaces. 

Cysts  of  the  Conjunctiva  are  generally  the  simple 
serous  cysts.  They  usually  appear  as  small  round  or 
oval  translucent  bodies,  and  occasion  inconvenience  only 
by  their  size  or  their  position.  Their  most  frequent  site 
is  in  the  fold  of  conjunctiva  which  is  reflected  from  the 
lower  lid  on  to  the  globe.  They  are  easily  removed  by 
first  seizing  them  with  a  pair  of  finely-toothed  forceps, 
and  then  with  a  pair  of  scissors  snipping  through  the 
portion  of  conjunctiva  which  holds  them. 

Warts  of  the  Conjunctiva  usually  grow  from  near 
the  tarsal  margins  of  the  lids,  but  they  may  spring  from 
other  portions  of  the  conjunctiva,  and  even  cover  a  large 
portion  of  the  globe.  They  may  either  be  pedunculated 
or  sessile. 

The  proper  treatment  is  excision. 

INJURIES   OP   THE   CONJUNCTIVA. 

EccHYMOSis  OF  THE  CONJUNCTIVA  —  Subconjunctival 
Hemorrhage — may  be  caused  by  a  blow  on  the  eye,  by 
coughing,  or  by  any  violent  exertion.  The  effused  blood 
at  first  appears  as  a  bright  red  mark,  abruptly  limited  to 
a  portion  of  the  conjunctiva,  but,  during  the  process  of 
absorption,  the  color  loses  its  intensity,  and  passes 
through  a  variety  of  shades  which  diffuse  themselves 
over  the  front  of  the  eye. 

Treatment A  few  days'  rest  is  generally  all  that  is 

required.  Cold  applications  are  grateful,  and  may  be 
used  either  by  allowing  the  patient  to  sponge  his  eyes 

4* 


42  DISEASES   OF   THE   CONJUNCTIVA. 

thi;ee  or  four  times  a  day  with  cold  water,  or  by  prescrib- 
ing for  him  some  cool  evaporating  lotion  (F.  31,  41). 

Lacerations  of  the  Conjunctiva  covering  the  eye, 
but  without  any  other  injury  to  the  eye  or  eyelids,  are 
generally  occasioned  either  by  the  patient  striking  his 
eye  against  some  sharp  projecting  object  which  catches 
the  conjunctiva  and  tears  it  as  the  head  is  moved  away  ; 
or  else  by  some  second  person  running  a  shutter,  or  a 
pole,  or  whatever  he  ma}^  be  cariying,  against  the  eye. 
The  injury  is  usually  followed  by  swelling  of  the  lids  and 
conjunctiva,  often  sufficient  to  render  it  difficult  to  make 
a  thorough  examination  of  the  eye  a  few  hours  after  the 
accident. 

Treatment.  —  The  eye  should  be  closed,  some  water- 
dressing  should  then  be  laid  over  the  lids,  and  fastened 
in  its  place  b}^  one  turn  of  a  roller.  It  is  very  rarely 
necessary  to  apply  any  sutures  to  keep  in  situ  Uie  torn 
edges  of  the  conjunctiva,  as  they  usually  fall  together  of 
their  own  accord ;  and  there  is  seldom  afterwards  any 
sufficient  strain  to  draw  them  apart  or  prevent  union. 
An  exceptional  case  might  occur,  in  which  sutures  would 
be  called  for ;  thus,  if  a  flap  of  the  conjunctiva  was  torn 
from  the  globe,  so  that  it  was  reflected  back  on  itself, 
one  or  two  fine  stitches  would  be  required  to  hold  it, 
after  it  had  been  restored  to  its  proper  position.  When 
all  the  swelling  of  the  lids  and  conjunctiva  has  completely 
subsided,  if  there  is  some  muco-purulent  discharge,  two 
or  three  drops  of  a  lotion  of  sulphate  of  zinc  (F.  20)  may 
be  dropped  into  the  eye  twice  a  day. 

For  diseases  and  injuries  of  the  conjunctiva  of  the  e^'e- 
lids,  see  section  Diseases  of  Eyelids. 


COKNEITIS.  43 


CHAPTER  11. 

DISEASES    OF    THE    CORNEA   AND    SCLEROTIC. 

"CoRNEiTis — Keratitis — Inflammation  of  the  Cornea — 
is  a  disease  of  impaii'ed  nutrition  most  frequently  seen 
in  children  and  young  people.  It  is  met  with  in  the  pale 
and  half-starved,  as  well  as  in  the  OA^er-fat  and  improp- 
erly fed  child ;  or  it  may  be  caused  from  some  constitu- 
tional taint,  such  as  struma  or  inherited  syphilis.  The 
two  latter,  however,  present  peculiarities  which  distin- 
guish them  from  the  simple  form  of  corueitis  we  are  now 
considering.  True  or  simple  corneitis  is  a  disease  which 
extends  itself  over  an  uncertain  period  of  time,  runs  a 
definite  course,  and  with  a  strong  tendency  to  get  well  if 
not  thwarted  by  the  injudicious  use  of  drops  and  nos- 
trums, suggested  by  the  zeal  of  the  surgeon  or  the  rest- 
lessness of  the  patient.  Corneitis  may  be  confined  to  the 
one  e^'e,  but  both  are  generally  affected.  It  usually  com- 
mences in  one  eye,  and  steadily  progresses  until  it  has 
reached  a  certain  stage,  when  the  second  eye  becomes 
attacked,  and  passes  through  exactly  the  same  series  of 
symptoms.  Both  eyes  are  now  affected,  but  the  one  in 
which  the  disease  began  is  in  advance  of  the  other,  and 
is  the  one  first  to  recover.  The  interval  which  elapses 
before  the  second  eye  is  involved  is  very  variable,  in  some 
cases  it  may  only  be  a  few  weeks,  in  others  as  long  as 
three  or  four  months.  The  progress  of  the  disease 
towards  recovery  is  verj^  slow ;  it  may  vary,  according  to 
the  acuteness  of  the  attack,  from  six  months  to  one  and 
a  half  or  two  j^ears,  dating  from  the  commencement  of 
the  attack  in  the  first  eye  to  the  ultimate  recovery  of  that 


44  DISEASES    OF   THE    CORNEA. 

in  the  second.     With  the  knowledge  of  these  facts,  the 
prognosis  of  the  surgeon  ought  to  be  guarded. 

Synvptoms. — The  disease  usually  commences  with  a 
pinkish  redness  of  the  ciliary  region,  shading  off  and  be- 
coming lost  in  the  general  whiteness  of  the  eye.  This 
redness  will  occasionally  be  at  first  confined  to  one  or 
more  vascular  patches  around  the  margin  of  the  cornea, 
or  there  may  be  present  from  the  very  beginning  a  dis- 
tinct pinkish  tinge  of  the  whole  ciliary  zone.  The  eye  is 
irritable  and  shirks  the  light.  The  cornea  now  begins  to 
look  hazy  and  the  sight  is  dimmed.  As  the  corneitis  ad- 
vances, the  haziness  of  the  cornea,  the  vascularity  of  the 
eye,  and  the  intolerance  of  light  increase.  The  brilliancy 
of  the  cornea  becomes  so  dulled  that  it  looks  like  a  win- 
dow-pane which  has  been  breathed  on,  or  like  a  piece  of 
ground-glass.  One  part  of  the  cornea  is  frequently  more 
deeply  affected  than  another,  and  a  patchy  appearance  is 
thus  given  to  the  cloudiness.  There  is  generally  consid- 
erable lachrj-mation,  and  oftentimes  a  good  deal  of  pain 
in  and  around  the  eye,  with  a  sense  of  grittiness  of  the 
lids.  The  disease  having  reached  its  height,  the  process 
of  repair  sets  in.  The  vessels  around  the  margin  of  the 
cornea  shoot  into  the  substance  of  the  corneal  tissue  and 
give  to  the  part  of  that  structure  which  they  invade,  a 
red  velvety  appearance.  In  ver}"  severe  cases  this  condi- 
tion of  pannus  will  extend  over  the  greater  part  of  the 
cornea.  It  is  quite  distinct  in  appearance  from  the  vas- 
cular cornea,  which  is  induced  by  the  friction  of  granular 
lids.  Gradually  this  excessive  vascularity  subsides,  and, 
as  the  bloodvessels  disappear  from  sight,  patches  of  cor- 
nea again  become  transparent,  until  at  length  the  repara- 
tive process  is  completed.  Such  is  the  course  of  a  simple 
uncomplicated  case  of  corneitis,  which,  having  run  through 
the  various  stages  of  the  disease  has  terminated  favora- 
bly.    The  disease,  however,  may  not  progress  so  satis- 


CORNEITIS.  45 

factoril}^,  aucl  ulcers  may  form  either  at  the  margin  or 
central  portion  of  the  cornea,  which  will  considerably 
retard  recovery.     (See  Ulcers  of  the  Cornea,  p.  58.) 

BesuJfs  of  Corneitis. — The  ej'e  may  corapletel}'  recover, 
the  cornea  regain  its  transparency,  and  the  sight  be  re- 
stored. Generally,  however,  even  in  favorable  cases,  the 
acnteness  of  vision  is  diminished,  either  by  a  haziness  so 
diffused  and  slight  as  not  to  be  noticed  by  an  ordinary 
observer,  or  else  by  a  faint  nebula  which  slightly  invades 
the  region  of  the  cornea  opposite  the  pupil.  When  the 
corneitis  has  induced  ulceration  or  sloughing  of  the  cor- 
neal tissue,  there  will  always  remain  a  more  or  less  dense 
nebula  or  leucoma. 

Chronic  Interstitial  Corneitis,  or  inflammation  of 
the  cornea  dependent  on  hereditary  syphilis,  was  first 
accurately  described  b}^  Mr.  Jonathan  Hutchinson  in  his 
work  on  Sj'philitic  Diseases  of  the  Eye  and  Ear,  pub- 
lished in  1863.  Patients  suffering  from  this  affection 
usuall}^  present  marked  signs  of  constitutional  syphiUs, 
or  evidence  can  be  obtained  from  the  parents  of  their 
having  had,  during  infancy,  some  specific  symptoms.  Mr. 
Hutchinson  states  that  in  almost  all  cases  the  subjects  of 
this  disease  "  present  a  ver^y  peculiar  physiognomy^  of 
which  a  coarse  flabby  skin,  pits  and  scars  on  the  face  and 
forehead,  cicatrices  of  old  fissures  at  the  angles  of  the 
mouth,  a  sunken  bridge  to  the  nose,  and  a  set  of  perma- 
nent teeth  peculiar  for  their  smallness,  bad  color,  and  the 
vertically  notched  edges  of  the  central  upiper  incisors,  are 
the  most  striking  characters."  *  He  also  notices  the  facts 
that  this  disease  is  frequently  accompanied  or  preceded 
by  iritis,  and  followed  by  such  changes  in  the  choroid  as 
are  often  seen  in  heredito-syphilitic  patients. 

*  Syphilitic  Diseases  of  the  Eye  and  Ear,  p.  30. 


4G  DISEASES   OF   THE   CORNEA. 

Symptoms. — The  disease  usually  commences  in  one  eye 
•with  a  diffuse  haziness  near  the  central  part  of  the  cor- 
nea, which,  when  carefully  examined,  is  found  to  consist 
of  dots  of  opacity  in  the  substance  of  the  corneal  tissue. 
These  interstitial  deposits  increase  in  number  and  size, 
whilst  some  of  them  coalesce  with  others,  gradually  ren- 
dering the  whole  cornea  opaque,  with  the  exception  of  a 
circumferential  band  which  commonly  retains  more  or  less 
of  its  transparency.  The  cornea  loses  its  brilliancy,  and 
ultimately  assumes  a  dull  ground-glass  appearance;  but 
the  cloudiness  is  seldom  uniform,  patches  of  it  being  of 
deeper  density  than  the  rest.  There  is  intolerance  of 
light,  var3-ing  in  intensity,  but  generally  not  ver}^  severe. 
There  is  supra-orbital  pain  and  redness  of  the  ciliary  zone 
of  vessels  around  the  cornea.  After  a  time  the  opacity 
of  the  cornea  begins  to  clear,  and  gradually  its  transpa- 
rency and  ijolish  are  either  partially  or  entirety  restored. 
It  is,  however,  very  rare  that  the  recovery  is  complete ; 
patches  of  nebulosity  remain  which  impair  vision  in  ac- 
cordance with  their  situation  and  density.  The  second 
eye  usualty  becomes  affected  from  one  to  three  months 
after  the  first  one,  and  runs  through  a  similar  course. 

In  this  disease  ulcers  of  the  cornea  seldom  occur.  The 
duration  of  an  attack  of  chronic  interstitial  corneitis  from 
its  commencement  in  one  eye  to  its  termination  in  the 
other,  is  general^  from  twelve  to  eighteen  months.  The 
time  will,  however,  necessarily  vary  with  the  extent  and 
severity  of  the  disease. 

Strumous  Corneitis  resembles,  in  its  general  charac- 
ters, the  simple  corneitis  already  described.  The  patients 
are  usually  children  or  young  persons,  who  exhibit  all 
the  characteristics  of  struma.  There  is  great  photopho- 
bia and  lachrymation,  and  a  peculiar  tendency  to  ulcera- 
tion, which  may  take  place  at  one  or  more  points  on  the 


CORNEITIS.  47 

surface  of  the  cornea.  The  disease  is  very  tedious,  and 
generally  both  eyes  are  aifected,  but  like  most  forms  of 
corneitis  one  e3'e  is  attacked  some  weeks  in  advance  of 
the  other. 

General  Treatment  of  Corneitis, — As  this  affection 
naturally  extends  over  a  long  space  of  time,  it  is  well  to 
remember  that  the  effects  of  remedies  are  slow,  and  that 
judicious  treatment  consists  rather  in  guiding  the  disease 
to  a  favorable  termination  than  in  the  endeavor  to  cut  it 
short  bj^  the  use  of  powerful  agents,  which  generally 
exert  a  prejudicial  influence. 

Constitutional  Treatment. — At  the  commencement  of 
the  attack  the  bowels  should  be  cleared  out  by  a  purga- 
tive (F.  123,  124,  128);  and  if  the  attack  is  acute,  and 
the  dread  of  light  severe,  a  saline  mixture  (F.  107),  or 
one  containing  small  doses  of  tartarated  antimon}^  (F. 
108),  may  be  prescribed ;  but  these  must,  in  a  few  da^'s, 
give  way  to  tonics  of  the  mineral  acids  with  cinchona  (F. 
110),  or  to  some  of  the  preparations  of  iron,  quinine,  or 
both  combined.  During  the  continuance  of  the  attack, 
the  state  of  the  health  should  be  carefully  attended  to, 
and  medicines  should  be  prescribed  or  omitted  as  the 
case  may  seem  to  demand.  Where  there  is  great  intol- 
erance of  light  and  lachrymation,  or  where  the  patient  is 
restless  and  sleeps  badly  at  night,  opiates  are  of  great 
service,  taking  care  that  during  their  administration  the 
bowels  act  regularly.  Small  doses  of  tinct.  opii,  or  tiuct. 
belladonnse  (F.  112),  may  be  given  with  the  bark  mix- 
ture every  four  hours  during  the  day ;  or  a  larger  dose  of 
the  opiate  maj^  be  ordered  ever3'  night.  In  children  of 
two  or  three  years  of  age,  a  powder  of  pulv.  ipecac,  comp. 
cum  potass,  nitrat.  (F.  120),  at  bedtime,  is  often  very 
useful  in  allaj'ing  the  excessive  irritability  and  restless- 
ness which  is  so  frequently  seen  in  corneitis. 


48  DISEASES    OF   THE    CORNEA. 

In  all  cases  of  inflammation  of  the  cornea,  or  indeed  of 
an}'  of  the  tissues  of  the  eye  in  which  there  is  a  dread  of 
light,  the  eyes  ought  to  be  protected  from  painful  expo- 
sure to  glare.  In  the  house  this  is  best  effected  by  draw- 
ing down  the  blinds,  or  partially  closing  the  shutters,  and 
b}'  shading  both  eyes  with  a  broad  light  shade;  but  out 
of  doors  dark-colored  glasses  should  be  used.  The  neu- 
tral tint  glasses  are  far  more  efficient  in  affording  relief 
from  glare  than  those  of  a  cobalt-blue  color.  The}-  may 
be  obtained  of  any  shade.  In  making  a  selection,  those 
neutral  tints  should  be  chosen  which  do  not  contain  much 
j-ellow.  The  cobalt-blue  glasses,  from  being  less  un- 
sightly, are  generall}'  preferred  b}'  the  patient,  and  in  the 
slight  cases  of  photophobia  answer  their  purpose  exceed- 
ingly well.  The  best  form  of  spectacles  are  those  with 
large  curved  glasses ;  they  sufiiciently  protect  the  eye 
from  light  and  wind,  whilst  they  do  not  make  it  hot. 

The  popular  s^'stem  of  tying  up  the  eye  with  a  hand- 
kerchief to  exclude  it  from  light,  is  essentially  wrong, 
and  should  not  be  allowed. 

In  the  Chronic  Interstitial  Coriieitis,  Mr.  Hutchinson 
recommends  "the  cautious  use  of  mercurials  and  iodides, 
at  the  same  time  supporting  the  system  b}'  tonics  and  a 
liberal  diet."  He  adA'ises  a  little  of  the  mild  mercurial 
ointment  to  be  rubbed  in  behind  the  ear,  or  beneath  the 
axilla,  ever}'  night,  but  a  strict  icatch  should  be  kept  to 
prevent  the  patient  from  becoming  salivated.  Inter- 
nally, the  syrup  of  the  iodide  of  iron  (F.  114),  or  the 
mist,  potassii  iodidi  cum  ferro  (F.  115),  may  be  ordered; 
but  should  these  medicines  disagree,  or  the  patient  be 
very  feeble,  tonics  of  iron,  quinine,  or  bark  may  be  sub- 
stituted. 

In  strumous  children^  cod-liver  oil  and  the  syrup  of  the 
iodide  of  iron  in  small  doses  do  much  good.  Where  there 
is  a  tendency  to  rickets,  the  phosphites  and  hypophos- 


CORNEITIS.  49 

phites  of  iron  and  lime,  either  singly  or  combined  (F. 
117),  are  often  of  service.  But  the  greatest  benefit  will 
be  derived  from  bracing  country  or  sea-side  air,  strict 
cleanliness,  and  a  well-regulated  nutritious  diet,  in  which 
pure  milk  and^ew-laicl  eggs  form  a  part. 

Local  Applications. — In  corneitis,  sedatives  to  the  eye 
give  great  relief,  and  of  these  belladonna  is  the  most  effi- 
cacious. When  there  is  great  irritability,  a  warm  fomen- 
tation of  belladonna  (F.  8)  may  be  applied  to  the  closed 
lids  bj^  means  of  a  cupped  sponge  ;  or,  if  cold  is  more 
agreeable  to  the  patient,  the  eye  may  be  frequently 
splashed  with  cold  water,  or  a  fold  of  lint  wet  with  the 
belladonna  lotion  (F.  32)  may  be  tied  over  the  lids,  and 
moistened  as  often  as  it  becomes  dry.  A  few  drops  of  a 
solution  of  atropise  sulph.  gr.  2  ad  aquae  ^  1  may  be 
dropped  two  or  three  times  a  day  into  the  eye  when  the 
dread  of  light  is  very  severe.  Thus  frequently  applied, 
it  acts  as  a  direct  sedative  to  the  ciliary  nerves,  and  also 
paralyzes  the  accommodative  power,  and  places  the  eye 
in  a  state  of  rest.  It  is,  however,  very  difficult  to  use 
atropine  drops  in  j^oung  children,  as  the  struggling  which 
ensues  whenever  the  attempt  is  made  to  put  them  into 
the  eye  often  does  more  harm  than  the  remedy  is  likely 
to  do  good.  In  such  cases  the  compound  belladonna 
ointment  (F.  98),  rubbed  in  over  the  brow  night  and 
morning,  or  the  belladonna  liniment  smeared  over  the 
brow,  will  probably  act  beneficially.  Stimulating  appli- 
cations to  the  eye  almost  invariably  do  harm ;  the^^  are 
very  painful,  and  increase  the  irritation. 

Counter-irritation  is  often  of  great  benefit.  The  brow 
and  integument  of  the  upper  ej^elid  may  be  painted  with 
the  linimentum  iodi,  taking  care  not  to  paint  it  too  thickly 
on  the  upper  lid.  A  stick  of  nitrate  of  silver  moistened 
with  water,  drawn  twice  or  three  times  across  the  slvin 
of  the  upper  lid,  is  a  good  counter-irritant,  and  sometimes 


50  DISEASES    OF   THE    CORNEA. 

does  rauch  good  in  relieving  excessive  photopliobia.  It 
must  be  applied  cautiously,  as  when  it  is  laid  on  too 
thickl}',  it  will  blister,  or  even  produce  a  slough  of  the 
skin,  and,  in  addition,  it  is  very  painful.  If  the  appli- 
cation of  the  iodine  or  the  nitrate  of  silver  affords  relief, 
it  ma}'  be  repeated  at  intervals  of  a  few  days  or  a  week. 

Diffuse  Suppurative  Corneitis  is  generallj-  the  re- 
sult of  an  injury,  such  as  a  contused  or  lacerated  wound 
of  the  cornea,  but  it  may  also  come  on  from  constitu- 
tional causes.  It  may  follow  an}^  operation  on  the  eye  in 
which  the  cornea  is  involved ;  and  it  is  one  of  the  most 
fatal  terminations  of  the  operations  for  cataract.  The 
state  of  health  of  the  patient  at  the  time  of  the  injury  de- 
termines very  much  the  form  of  the  inflammation  which 
may  arise  from  it.  A  simple  incised  wound  or  an  abra- 
sion of  the  cornea,  from  which  a  strong  healthy  person 
would  probably-  recover,  without  an  untoward  symptom, 
in  a  few  days,  may  be  sufficient  to  induce  in  an  unhealthy 
patient  a  diffuse  suppurative  corneitis  which  will  destroy 
the  e^'e. 

Symptoms. — The  cornea  grows  dull  and  steamy;  pus  is 
effused  between  its  lamellae,  at  first  only  in  a  small  quan- 
tity at  one  sjjot ;  but  it  soon  increases  and  ditluses  itself 
throughout  the  corneal  structure.  In  severe  cases  I  have 
seen  the  whole  tissue  of  the  cornea  pervaded  with  pus, 
but  in  the  slighter  ones  it  is  geuerall}'  confined  to  one 
part. 

The  eye  is  hot  and  painful ;  there  is  great  congestion 
of  the  conjunctival  and  sclerotic  vessels,  dread  of  light, 
and  lachr3'matiou.  The  deeper  parts  of  the  e3'e  partici- 
pate in  the  inflammation,  the  iris  loses  its  mobility,  the 
aqueous  becomes  seroiis,  and  pus  is  efiused  into  the  ante- 
rior chamber  (hypopion). 

The  pus  between  the  la^'ers  of  the  cornea  now  makes 


CORNEITIS.  51 

an  exit  for  itself,  and  this  it  does  by  progressive  ulcera- 
tion either  anteriorly  towards  the  surface,  or  posteriorly 
into  the  anterior  chamber.  In  the  majority  of  cases  the 
corneal  abscess  bursts  anteriorly,  and  a  sloughing-looking 
ulcer  is  left. 

BesuUs  of  Suppurative  Corneitis. — If  the  whole  cornea 
has  been  involved  in  a  diffuse  suppurative  inflammation, 
and  pus  has  been  effused  throughout  the  whole  or  greater 
part  of  the  corneal  tissue  complete  loss  of  the  eye  must 
follow.  If,  however,  the  abscess  of  the  cornea  has  been 
limited  in  extent,  the  eye  may  recover,  but  a  leucoma  will 
remain,  which  will  impair  the  sight  in  proportion  to  its 
size,  density,  and  position  with  respect  to  the  pupil. 

It  will  be  well  to  explain  here  the  meanings  of  the 
terms  hypopiou,  onyx,  and  abscess  of  the  cornea,  as  con- 
siderable confusion  prevails  amongst  students  as  to  their 
right  application. 

Hypopioyi  is  an  effusion  of  pus  into  the  anterior 
chamber. 

Onyx  is  often  indefinitely  used  to  signify  a  collection 
of  pus  between  the  lamellae  of  the  cornea ;  but  it  is  only 
applicable  to  those  small  effusions  at  the  lower  pai't  of  the 
cornea,  from  the  fancied  resemblance  of  which  to  the  pos- 
terior end  of  the  finger-nail  it  has  derived  its  name. 

Abscess  of  the  Cornea  and  Onyx  are,  by  many,  regarded 
as  synonymous  terms ;  but  as  the  word  "  onyx  "  indicates 
the  appearance  and  locality  of  the  disease  rather  than  the 
disease  itself,  the  term  "  abscess  "  should  be  considered 
as  applicable  to  those  larger  effusions  of  pus  between  the 
corneal  lamellae  into  which  onyx  occasionally  passes,  or 
to  the  diffused  purulent  infiltrations  which  are  the  result 
of  diffuse  suppurative  corneitis. 

Treatment. — Warm  fomentations  of  belladonna  (F.  8), 
or  of  poppy-heads  to  the  eye ;  and,  in  the  intervals,  be- 
tween using  the  fomentations,  a  fold  of  linen  wet  with  the 


52  DISEASES   OF   THE   CORNEA. 

belladonna  lotion  (F.  32)  maj^  be  laid  over  the  closed  lids. 
It  will  be  useless  to  attempt  to  evacuate  the  pus  from 
between  the  corneal  laniellix?,  it  is  so  thick  and  iiifdtrated 
that  it  will  not  escape  through  any  external  incision. 
Parace»tesis  of  the  cornea,  or  tapping  the  anterior  cham- 
ber with  a  broad  needle  and  letting  the  aqueous  slowly 
escaj^e  will  often  be  of  service,  and  may  be  repeated  at 
intervals  of  one  or  two  daj'S  if  it  gives  relief. 

Paracentesis  of  the  Cornea  may  be  performed  as  fol- 
lows :  A  broad  needle  is  made  to  puncture  the  cornea 
towards  its  lower  margin,  the  point  being  kept  well  for- 
wards towards  the  cornea  to  avoid  wounding  the  lens, 
when,  by  suddenly  turning  the  flat  of  the  blade  on  to  its 
edge  so  as  to  render  patulous  the  opening  it  has  made, 
the  aqueous  is  allowed  to  nin  off.  As  soon  as  the  iris 
closely  approaches  the  cornea,  which  it  will  do  when  the 
aqueous  has  nearly  escaped,  the  blade  of  the  needle 
should  be  again  turned  on  the  flat,  and  quickl}^  with- 
drawn from  the  eye. 

For  the  constitutional  treatment,  the  patient  should  be 
supported  with  a  liberal  diet  and  a  fair  allowance  of  wine 
or  beer.  Diffusible  stimulants  (F.  54)  and  tonics  (F.  63, 
64)  are  the  most  suitable  medicines  ;  and  if  there  is  much 
pain  or  inability  to  sleep,  oj^iates  should  be  given  either 
in  small  doses  during  the  da}',  or  in  one  full  dose  at  bed- 
time. Attention  should  be  paid  to  the  regular  and  healthy 
action  of  the  bowels,  and,  if  necessary,  some  mild  purga- 
tive or  alterative  be  prescribed. 

Marginal  Corneitis. — This  name  is  well  applied  to 
a  low  form  of  inflammation  which  commences  at  the  ex- 
treme border  of  the  cornea,  and  creeps  on  slowly,  slightl}' 
invading  the  corneal  tissue  for  a  short  distance,  but  sel- 
dom, if  ever,  involving  the  whole  of  its  structure. 

Sijmptoms. — It  commences  with  slight  dread  of  light, 


CORNEITIS.  53 

lachrymation,  and  grittiness  of  the  eye,  which  increase 
in  intensity  as  the  disease  advances.  On  examining  the 
eye,  there  will  be  found  at  one  spot  close  upon  the  cor- 
nea a  vascular  patch,  and  the  corneal  edge  which  corres- 
ponds to  it  looks  swollen  and  softened.  This  condition 
may  involve  a  third  or  even  more  of  the  margin  of  the 
cornea,  but  it  seldom  includes  the  whole  of  its  circumfer- 
ence. In  a  few  days  a  small  diffused  haze  will  be  noticed 
near  the  margin  of  the  cornea,  and  this  will  gradually  ex- 
tend, sometimes  so  as  to  include  the  part  which  is  oppo- 
site the  pupil,  but  it  rarely  invades  the  whole  cornea. 
Occasionally  this  form  of  corneitis  is  accompanied  with 
one  or  more  small  marginal  herpetic  ulcers,  so  as  closely 
to  resemble  the  phlyctenular  ophthalmia.  The  disease 
is  tedious ;  it  may  be  acute  at  the  onset,  but,  in  its  dura- 
tion and  recovery,  it  is  generally  chronic.  It  is  also  very 
recurrent.  The  patients  who  are  most  liable  to  marginal 
corneitis,  are  those  who  are  in  a  low 'state  of  health.  It 
is,  consequentl}',  met  with  amongst  the  anxious  and  over- 
worked, and  in  mothers  who  are  enfeebled  from  over- 
lactation  ;  or  it  may  be  brought  on  by  any  exhausting 
disease,  such  as  leucorrhoea  or  menorrhagia. 

Tr-eatment. — The  eye  should  be  shaded  from  strong 
lights,  and  rested,  as  far  as  practicable,  by  the  avoidance 
of  reading,  writing,  and  all  kinds  of  close  work.  If  there 
is  much  dread  of  light,  gutt.  atropire  (F.  13)  maybe  used 
once  or  twice  daily ;  or  the  Qje,  may  be  bathed  frequently 
with  a  lotion  of  atropine  (F.  31),  or  of  belladonna  (F.  32). 
If  the  marginal  corneitis  is  apparently  dependent  on 
overwork  or  close  confinement  to  business,  change  of  air 
and  recreation  are  the  most  powerful  curative  agents. 
The  medicines  which  do  the  most  good  are  tonics  of  bark 
or  iron,  combined  with  the  mineral  acids,  or  with  small 
doses  of  liq.  strychnise,  or  tinct.  nucis  vomicae  (F.  59, 
60,  61,  68,  70). 

5* 


54  DISEASES    OF   THE    CORNEA. 

Phlyctenular  Ophthalmia — Scrofulous  Ophthalmia 
— is  most  frequent  in  young  children  from  two  years  old 
and  upwards ;  but  it  is  seldom  seen  in  patients  after  the 
age  of  puberty.  It  is  characterized  by  intense  intoler- 
ance of  light ;  the  photophobia  is  greater  in  this  than  in 
an}'  other  disease  of  the  eyo..  In  severe  cases  the  child 
is  commonly  seen  with  the  lids  tightly  closed,  and  with 
a  fist  over  each  eye,  or  Avith  his  face  buried  in  the  dress 
of  the  nurse  who  is  carr3'ing  him.  An}-  attempt  to  look 
at  the  e3'es  is  met  by  violent  spasmodic  contraction  of  the 
lids,  and  if,  after  severe  struggles,  the  lids  are  parted,  the 
globe  is  found  to  be  so  turned  upwards  that  it  is  impos- 
sible even  to  see  the  cornea.  The  exposure  of  the  ej'e 
to  the  slightest  light  often  brings  on  a  fit  of  rapid  sneez- 
ing. In  such  cases,  when  it  is  desired  to  see  the  63-6, 
the  child  should  be  given  a  few  sniffs  of  chloroform,  suf- 
ficient to  dull  his  sensibility,  without  putting  him  com- 
pletely under  its  influence.  An  examination  can  then 
be  made  without  any  struggling,  but,  in  addition  to 
this  the  chloroform  often  exerts,  by  its  sedative  influ- 
ence, a  very  beneficial  effect  on  the  e3'e,  and  the  child 
awakes  from  his  sleep  with  a  decided  diminutioji  of  the 
photophobia.  It  will  be  often  found  that  the  severit}^  of 
the  s3'mptoms  is  quite  out  of  proportion  to  the  apparent 
disease ;  frequently  there  is  but  little  to  be  seen  except 
one  or  more  small  phl3ctenulre  close  upon  the  margin  of 
the  cornea.  These  phlycteuulffi  are,  however,  of  an  her- 
petic nature,  and  run  a  course  somewhat  similar  to  an 
herpetic  eruption  on  other  parts  of  the  bod3\  At  first 
the}^  appear  as  small  vesicles,  the  contents  of  which  soon 
become  turbid;  the  vesicles  then  burst  and  form  small 
superficial  ulcers,  which  eventuall}'  heal  without  leaving 
any  visible  scars  to  show  where  the3^  have  been.  The 
whole  ej^e,  in  some  cases,  is  much  bloodshot,  whilst  in 
other  instances,  when  the  lids  are  first  opened,  the  con- 


PHLYCTENULAR   OPHTHALMIA.  55 

jnnctiva  is  found  to  be  scarcely  tinged,  but  it  soon  flushes 
up  on  exposure  to  the  light.  Occasionally  a  leash  of  red 
vessels  may  be  seen  running  up  to  one  or  two  of  the 
phlyctenule. 

Scrofulous  ophthalmia  is  more  frequent  amongst  the 
poor  than  the  rich ;  the  strumous  child  is  the  most  liable 
to  it,  but  the  impure  air  of  dirty,  confined  lodgings,  com- 
bined with  an  insufficiency  of  sunlight,  improper  diet, 
and  want  of  care,  will  induce  the  disease  in  children  who, 
under  more  favorable  circumstances,  would  not  sutTer 
from  it.  This  form  of  ophthalmia  is  frequently  associated 
with  eczema,  impetigo,  sores  about  the  nose  and  lips,  and 
with  enlarged  cervical  glands,  indeed  with  all  those  kin- 
dred complaints  which  are  so  frequently  met  with  amongst 
the  poor  scrofulous  children  in  a  London  hospital.  Scrof- 
ulous ophthalmia  is  tedious  in  its  progress,  and  very  re- 
current. 

Treatvient. — During  the  early  and  acute  stage  of  the 
disease,  when  the  photophobia  is  very  intense,  the  vinum 
antimoniale,  in  doses  of  from  njjlO  to  Tt)2  20  every  four 
hours,  often  exercises  an  almost  speciiic  effect  in  reliev- 
ing the  dread  of  light.  If,  however,  it  fails  to  do  decided 
good  in  three  or  four  daj^s,  it  should  be  discontinued. 
Sedatives  will  sometimes  prove  of  great  service,  and 
small  doses  of  tinct.  hyoscyami,  succus  conii,  tinct.  bella- 
donna?, tinct.  opii,  or  sol.  morphite  muriat.,  may  be  given 
singly  at  short  intervals  during  the  day ;  or  they  may  be 
combined  with  bark,  or  with  the  mineral  acids,  or  with 
an}^  other  medicine  which  the  state  of  the  patient  may 
suggest.  Where  there  is  much  debility  with  languor,  and 
restlessness  at  night,  mist,  cinchonse  (F.  110,  111),  may 
be  prescribed  during  the  day,  and  pulv.  ipecac,  comp. 
cum  potass,  nitrate  (F.  120),  in  doses  of  gr.  3  or  gr.  4, 
according  to  the  age  of  the  patient,  at  bedtime. 

The  preparations  of  iron  are  very  valuable  in  scrofu- 


56  DISEASES    OF   THE    CORNEA. 

lous  ophthalmia,  but  they  should  not  be  coutinued  for 
too  long,  or  be  ordered  with  a  hot  skin  and  furred  tongue. 
In  decidedly  scrofulous  children,  the  syrup,  ferri  iodid. 
or  the  syrup,  ferri  hypophosphit.  in  doses  n)j  15  to  tijj  20, 
twice  a  day  in  water,  are  of  much  benefit.  Where  there 
is  simply  anaemia,  the  ferrum  redactum  gr.  ^  to  gr.  1,  or 
the  ferri  carl),  cum  saccharo,  in  doses  of  from  gr.  1  to  gr. 
5,  are  the  best.  Cod-liver  oil  may  be  often  advantageously 
prescribed  with  the  iron  ;  it  is  especiallj^  serviceable  where 
there  are  evidences  of  failing  nutrition.  The  regular  and 
healthy  action  of  the  bowels  should  be  strictly  attended 
to,  and  purgatives  ordered  when  necessary.  If  the  child 
suffers  from  ascarides,  means  should  be  taken  to  rid  him 
of  them.  This  is  best  done  by  an  injection  of  two  or 
three  ounces  of  infusion  of  quassia  into  the  rectum ;  or, 
if  this  fails,  an  injection  with  a  few  minims  of  tinct.  ferri 
sesquichlorid.  to  the  ounce  of  water  may  be  used.  After 
the  injection,  a  powder  of  cal.  cum  scammon  (F.  127, 
128)  should  be  given. 

Local  apjMcations  may  be  considered  under  two  head- 
ings :  a.  Sedatives  to  the  eye.     /3.  Counter-irritants. 

a.  Sedatives  to  the  Eye. — Of  these  the  most  useful  is 
the  sulphate  of  ati'opia,  a  solution  of  which  gr.  1  ad  aquae 
^  1  may  be  dropped  into  the  eye  three  or  four  times  daily. 
Unfortunately  the  use  of  this  remedy  is  very  often  im- 
practicable, from  the  resistance  the  child  offers  to  every 
attempt  to  put  the  drops  into  the  63*6.  When  there  is 
much  struggling  the  drops  ought  to  be  discontinued. 
Much  comfort  is  frequently  obtained  from  bathing  tlie 
eyes  with  the  belladonna  lotion  (F.  32),  and,  when  the 
child  is  asleep,  applying  a  fold  of  linen  wet  with  the  lo- 
tiou  over  the  closed  lids ;  or  iced  water  may  be  used  in  a 
similar  manner.  The  belladonna  liniment  of  the  British 
Pharmacopeia  rubbed  into  the  brow  Avill  occasionally 
aflbrd  ease ;  or  the  unguent,  belladonna}  comp.  (F.  98), 


CORNEO-IRITIS.  57 

may  be  applied  over  the  brow  and  temple,  and  allowed  to 
remain  on  dnring-  the  daj^  When  there  is  eczema  of  the 
lids,  the  best  application  is  the  lotio  boracis  (F.  48). 

/?.  Counter-irritants. — 1.  A  stick  of  nitrate  of  silver 
moistened  with  water  may  be  drawn  once  or  twice  across 
the  skin  of  the  npper  lid.  It  is  a  painful  application,  but 
it  frequentl}'  gives  marked  relief. 

2.  The  liuimentum  iodi  may  be  painted  over  the  brow 
and  upper  eyelid,  taking  care  that  none  of  it  runs  between 
the  lids  into  the  e^-e.  Over  the  integument  of  the  lid  it 
must  be  painted  lightly,  as  it  soon  blisters. 

3.  Small  blisters,  the  size  of  a  sixpence  or  shilling,  ap- 
plied to  the  temple.  If  the  emplast.  cantharidis  is  used, 
the  blisters  should  be  removed  at  the  expiration  of  four 
hours.  For  children,  the  best  and  least  painful  blister  is 
Brown's  cantharidine  or  blistering  tissue. 

Corned-Iritis  is  an  inflammation  of  the  cornea  and  iris. 
The  disease  usually  commences  in  the  cornea,  and  after- 
wards extends  to  the  iris.  It  mostly  occurs  in  patients 
enfeebled  by  disease  or  excessive  work,  and  in  those  who 
have  previously  suffered  from  sjphilis. 

Symptoms Haziness  of  the  cornea,  ciliary  redness,  a 

sluggish  and  irregular  pupil,  pain  in  the  eye  and  around 
the  orbit,  and  frequently  great  photophobia  and  lachry- 
mation. 

Treatment The  pupil  should  be  kept  dilated  with  the 

guttae  atropiae  (F.  13),  dropped  twice  dailj'  into  the  ej'e, 
or  the  lotio  belladonnje  (F.  32)  may  be  frequently'  used. 
If  there  be  much  pain  in  the  eye  and  around  the  brow,  a 
little  of  the  unguent,  hydrarg.  cum  belladonna  (F.  99), 
rubbed  into  the  temple  night  and  morning,  often  affords 
relief.  As  the  patient  is  generall}'  in  a  low  state  of  health, 
tonics  of  quinine  and  iron  (F.  65,  66),  or  bark  with  the 
mineral  acids  {F.  61),  should  be  prescribed.   When,  how- 


58  DISEASES   OF   THE   CORNEA. 

ever,  there  is  a  distinct  sj'philitic  history,  the  mist,  potass, 
iodid.  (F.  74),  or  the  mist,  potass,  iodid.  cum  ferro  (F. 
T3),  should  be  given.  It  is  seldom  advisable  to  give  mer- 
cury internally  in  these  cases.  The  disease  is  one  of  low 
power,  and  all  the  benefit  lil^ely  to  be  gained  from  mer- 
cury will  be  obtained  by  the  inunction  of  the  unguent, 
hydrarg.  cum  belladonna  into  the  temple. 

ULCERS   OF   THE   CORNEA. 

Ulcers  of  the  Cornea  may  be  caused  by  seA^ere  in- 
flammation of  the  conjunctiva  or  cornea,  and  may  occur 
during  the  progress  of  the  attack.  They  are  thus  fre- 
quentl}^  seen  in  purulent  and  gonorrhoeal  ophthalmia,  and 
in  corneitis,  especially  in  the  strumous  and  diffuse  sup- 
purative forms  of  the  disease.  There  are,  however,  some 
special  ulcers  which  seem  to  originate  in  the  cornea,  and 
not  to  be  secondary  to  active  inflammation  of  either  that 
structure  or  of  the  conjunctiva.  Ulcers  of  the  cornea 
are  always  indicative  of  impaired  health,  and  are  conse- 
quently met  with  in  the  feeble,  the  overworked,  the  stru- 
mous, and  the  rheumatic  patient.  The}^  are  alwaj's  ac- 
companied with  i^ain  and  grittiness  of  the  eye,  photopho- 
bia and  lachrymation.  The  cornea,  except  in  the  imme- 
diate vicinity  of  the  ulcer,  may  retain  its  transparency^, 
but  the  conjunctival  surface  of  the  globe  is  usually  more 
or  less  reddened,  and  rapidly  flushes  on  undue  exposure 
of  the  eye  to  light.  Ulcers  of  the  cornea  may  be  either 
acute  or  chronic,  superficial  or  deep. 

Superficial  Ulcers  of  the  Cornea  are  most  fre- 
quently met  with  in  young  people,  and  especially  in  deli- 
cate children.  The  disease  may  be  confined  to  one  eye, 
or  both  may  be  affected,  or  they  may  be  attacked  alter- 
nately.    There  is  considerable  photophobia  and  lachry- 


ULCERS    OF   THE   CORNEA.  59 

mation,  with  a  sense  of  heat  and  grittiness  in  the  e3'e. 
There  are  two  forms  of  superficial  ulcers  of  the  cornea : 
the  nebulous  and  the  transparent  ulcer. 

The  Superficial  Nebulous  Ulcer  may  occur  at  any  part 
of  the  cornea,  either  towards  its  periphery  or  its  centre. 
Carefully  examined,  it  appears  as  a  small,  irregular,  ill- 
defined,  grayish-looking  ulcer.  The  edges  of  the  ulcer 
are  frequently  slightly  raised,  and  of  a  darker  gray  tinge 
than  the  central  portion,  which  will  be  found  occasionally 
almost  transparent.  The  ulcer  having  been  formed,  it 
may  remain  almost  stationary  for  a  short  time,  and  then 
begin  to  heal.  This  is  the  course  which  such  superficial 
ulcers  usually  run ;  it  is  exceptional  for  them  to  penetrate 
deeply  the  corneal  tissue  and  to  lead  to  perforation  and 
prolapse  of  the  iris.  As  the  ulcer  advances  towards  re- 
covery, it  first  assumes  a  more  opaque  appearance ;  the 
central  excavation  then  becomes  filled  in  and  its  edges 
bevelled.  Frequently  one  or  more  red  vessels  may  be 
seen  running  to  it  from  the  margin  of  the  cornea ;  these 
are  vessels  of  repair,  and  ought,  when  they  have  accom- 
plished their  duty,  to  become  so  reduced  and  contracted 
as  to  cease  to  be  visible,  or  to  interfere  with  the  normal 
transparency  of  the  cornea.  Graduall}^  the  opacity  of  the 
healing  ulcer  is  reduced,  and  day  by  day  the  parts  slowly 
become  clearer,  until  at  length  complete  or  partial  trans- 
parencj  is  restored.  These  ulcers  of  the  cornea  are  gen- 
erallj^  acute  at  their  onset,  but  they  will  often  drift  into 
the  chronic  state. 

Superficial  Transparent  Ulcers  of  the  Cornea. — The 
symptoms  which  accompany  the  formation  and  progress 
of  these  ulcers,  resemble  those  of  the  nebulous  ulcer  just 
described,  and  they  occur  amongst  the  same  class  of  pa- 
tients. There  is  the  same  photophobia  and  lachrymation, 
with  redness  of  the  eye  on  exposure  to  light ;  the  only 
characteristic  diff"erence  being  the  appearance  of  the  ulcer. 


60  DISEASES    OF   THE    CORNEA. 

On  gently  raising  the  lids  so  as  to  examine  the  eye,  the 
epithelium  of  the  cornea  seems  as  if  it  were  abraded  or 
scratched  off  at  one  or  more  points.  The  transparency 
and  polish  of  the  cornea  at  this  stage  of  the  disease  is 
unimpaired,  and  each  ulcer,  if  there  be  more  than  one,  is 
seen  as  a  glistening  facet.  The  first  indication  of  a  heal- 
ing action  in  these  ulcers  is  shown  b}^  their  losing  their 
transparency  and  becoming  gray  and  cloudy,  the  cloudi- 
ness often  extending  beyond  the  margin  of  the  ulcer. 
Their  clear  outline  is  soon  lost,  their  slight  excavation 
filled  in,  and  the  even  surface  of  the  cornea  is  restored. 
If  the  ulcer  has  not  penetrated  below  the  epithelium, 
transparency  is  regained ;  but  if  it  has  extended  into  the 
true  corneal  structure,  a  nebula  or  semi-transparent  leu- 
coma  will  be  afterwards  left. 

Treatment. — Soothing  applications  to  the  eye,  which 
may  be  used  either  hot  or  cold  in  accordance  with  the 
feelings  of  the  patient.  Fotus  papaveris,  lotio  belladonnae 
(F.  32),  or,  if  there  is  great  irritability^,  the  gutt£e  atropias 
(F.  13),  dropped  into  the  eye  three  or  four  times  dail}'. 
All  stimulating  drops  or  lotions  are  injurious.  In  chil- 
dren, an  alterative  powder  of  hydrarg.  cum  creta  cum 
rheo  (F.  122,  123),  given  ever}'  second  or  third  night,  is 
very  beneficial.  If  the  skin  is  hot  and  the  tongue  furred, 
the  mist,  salin.,  or  mist,  antimonii  tartarati  (F.  10*7,  108), 
should  be  ordered ;  but  as  soon  as  the  secretions  have 
become  healthy,  bark,  the  mineral  acids,  preparations  of 
iron,  and  cod-liver  oil,  are  the  most  suitable  remedies. 

Deep  Ulcers  of  the  Cornea. — The  superficial  ulcers 
described  in  the  preceding  paragraphs  may  become  deep, 
and  so  be  rightl}^  included  under  this  heading ;  but  this 
is  not  the  course  they  usually  pursue.  There  are,  how- 
ever, certain  ulcers,  the  tendency  of  which  is  to  extensive 
destruction  of  corneal  tissue,  leading  frequently  to  per- 


ULCERS    OF   THE    CORNEA.  61 

foration  and  prolapse  of  the  iris,  and  to  these  the  term 
"  deep  "  is  fitly  applied.  They  may  be  seen  in  patients 
of  all  ages,  and  unless  produced  by  injury,  are  usually 
dei:)endeut  on  some  constitutional  defect.  Generally  they 
proceed  from  want,  but  occasionally  from  excess. 

Sloughing  Ulcers  of  the  Cornea  may  be  the  result 
of  a  diffuse  suppurative  corneitis,  induced  either  by  in- 
jury or  disease,  the  pus  between  the  lamellae  of  the  cor- 
nea having  worked  its  way  to  the  surface  by  progressive 
ulceration.  Thej^  may  also  occur  amongst  the  half-starved 
and  overworked,  as  well  as  the  drunken  and  dissipated. 
They  must  be  then  regarded  as  evidences  of  failing  nu- 
trition and  want  of  nervous  power.  A  sloughing  ulcer  of 
the  cornea  usually  presents  an  irregularly  excavated  sur- 
face, with  a  whitish  yellow,  sloughy  appearance,  and  with 
its  margins  shelving  and  ill-defined.  Around  the  ulcer 
the  cornea  is  hazy.  These  ulcers  often  lead  to  complete 
destruction  of  the  e3^e  for  all  visual  purposes ;  but  even 
when  they  yield  to  treatment  and  the  eye  recovers,  it  is 
always  a  more  or  less  damaged  organ.  Sometimes  they 
will  perforate  the  cornea,  and  prolapse  of  the  iris  will 
follow ;  or  occasionally  they  will  penetrate  the  true  cor- 
neal tissue,  but  their  further  progress  will  be  stopped  by 
the  postei'ior  elastic  lamina  or  Descemet's  membrane. 
An  aperture  is  then  seen  in  the  cornea,  the  bottom  of 
which  is  closed  by  a  transparent  membrane  (Descemet's), 
which  projects  slightly  into  the  wound.  In  this  condition 
I  have  seen  the  eye  remain  for  man^^  weeks ;  the  corneal 
wound  may  then  begin  to  granulate  and  heal,  but  gener- 
ally the  posterior  elastic  lamina  in  the  end  gives  way,  the 
iris  prolapses,  and  cicatrization  follows.  During  the  heal- 
ing process,  the  cornea  in  the  immediate  vicinity  of  the 
ulcer  becomes  more  cloudy,  red  vessels  are  seen  invading 
its  substance  and  running  towards  the  ulcer,  and  in  some 

6 


G2  DISEASES    OF    THE    CORNEA. 

cases  in  such  numbers  as  to  present  a  perfect  pannus  ; 
but  these  disappear  from  sight  as  soon  as  cicatrization  is 
completed.  The  cornea  in  the  locality  of  the  ulcer  may- 
resume  its  transparency,  but  the  new  material  which  has 
replaced  that  lost  by  ulceration  will  be  more  or  less 
opaque  and  leucomatous. 

Treatment  (see  Treatment  or  Diffuse  Suppurative 
CoRNEiTis). — There  are,  however,  a  few  points  to  be  spe- 
cially noticed.  All  stimulating  applications  to  the  ulcer, 
as  a  rule,  do  harm.  The  touching  the  ulcer  with  a  stick 
of  the  diluted  nitrate  of  silver,  as  recommended  by  some, 
is,  I  believe,  in  most  cases,  positively  prejudicial.  When 
there  is  severe  pain  in  the  eye,  paracentesis  of  the  cornea 
will  often  afford  mucli  relief.  In  a  sloughing  ulcer  of  the 
cornea,  with  increased  intraocular  tension,  an  iridectomy 
;  is  of  the  greatest  service.  I  have,  in  .my  own  practice, 
seen  the  whole  train  of  distressing  symptoms  immediately 
relieved  by  the  operation ;  the  ulcer  has  taken  on  a  heal- 
ing action,  and  the  eye  has  rapidly  recovered. 

Crescentic  or  Chiselled  Ulcers  of  the  Cornea. — 
This  is  one  of  the  worst  and  most  intractable  forms  of 
ulceration  to  which  the  cornea  can  be  subjected,  but,  for- 
tunately, it  is  one  of  the  most  rare.  I  have  called  these 
ulcers  "crescentic,"  from  their  shape,  and  "chiselled," 
from  their  peculiar  characteristic  appearance,  as  if  a  poi*- 
tion  of  the  epithelium  and  true  corneal  tissue  had  been 
cut  away  with  a  chisel,  or  scooped  out  with  the  thumb- 
nail from  the  margin  of  the  cornea.  The}'  alwa3'S  occur 
at  the  extreme  edge  of  the  cornea,  but  they  are  strictly 
confined  to  that  structure,  and  do  not  in  the  slightest  de- 
gree encroach  upon  the  sclerotic.  In  their  progress  they 
follow  exactly  the.  curve  of  the  rim  of  the  cornea,  by 
which  they  are  abruptly  limited,  the  circumferential  edge 
of  the  ulcer  being  cut  sharply  and  deepl}'.     They  spread 


ULCERS    OF   THE    CORNEA.  63 

rapidly  and  increase  both  in  length  and  depth.  There 
may  be  two  or  even  three  of  these  ulcers  at  different  parts 
of  the  margin  of  the  cornea,  and,  unless  their  progress 
be  arrested,  thej^  may  spread  and  unite,  and  so  insulate 
the  central  portion.  At  the  commencement  of  the  dis- 
ease, the  ulcei's  are  perfectly  transparent.  It  is  during 
their  healing  stage  that  they  grow  nebulous.  They  fre- 
quently perforate  the  cornea,  and  cause  extensive  pro- 
lapse of  the  iris ;  or,  as  in  the  sloughing  ulcers,  the  ad- 
vance of  the  ulceration  may  be  stopped  b}^  the  posterior 
elastic  lamina  of  the  cornea ;  but  this  usually,  in  the  end, 
gives  way,  and  prolapse  of  the  iris  ensues.  During  the 
reparative  process,  they  become  first  cloudy,  then  of  a 
grayish-white  color ;  vessels  shoot  into  them  from  their 
sclerotic  border,  and  they  are  ultimately  filled  in  with  a 
semi-opaque  cicatricial  tissue.  These  crescentic  ulcers 
are  the  source  of  great  pain  in  the  eye  and  around  the 
orbit,  accompanied  with  photophobia  and  lachrymation 
on  the  slightest  exposure  to  light.  They  do  not  seem  to 
be  connected  in  any  way  with  an}^  constitutional  taint, 
such  as  syphilis  or  struma.  The  patients  whom  I  have 
seen  affected  by  them  have  alwa3's  been  in  that  state  of 
health  which  is  best  described  as  "  being  thoroughly  out 
of  condition." 

Treatment. — These  ulcers  are  so  intractable,  and  so 
many  means  have  been  tried  without  success  to  check 
their  progress,  that  it  is  difficult  to  saj'  what  is  the  wisest 
course  to  pursue.  My  own  experience  is,  that  it  is  best 
to  leave  the  ulcers  alone,  and  to  apply  either  hot  fomen- 
tations or  cold  lotions  of  belladonna  (F.  8,  32)  to  the  eye. 
If  these  do  not  give  relief,  the  gutt.  atropiae  (F.  13)  may 
be  used  two  or  three  times  daily,  and  a  compress  band- 
age (F.  2)  be  applied  over  the  closed  lids  so  as  to  keep 
the  eye  as  much  as  possible  at  rest.  All  exposui'e  to 
strong  light  should  be  strictly  avoided  b}'  obliging  the 


64  DISEASES    OF    THE    COKXEA. 

patient  to  shade  his  ej-es,  and  to  keep  the  room  in  which 
he  lives  darkened.  A  liberal  diet  and  tonics  with  diffu- 
sible stimuli  should  be  ordered,  and  if  there  is  nnieh  pain 
opiates  ma}'  be  given  either  in  small  doses  at  short  inter- 
vals, or  in  one  full  dose  at  bedtime.  In  two  cases  I  have 
seen  a  partial  syndectomy  performed  by  excising  close  up 
to  the  margin  of  the  cornea  a  portion  of  the  conjunctiva 
and  subconjunctival  tissue,  about  ith  inch  in  width,  and 
in  a  line  exactly  corresponding  with  the  ulcer,  but  in  both 
it  failed  to  do  any  good,  Mr.  Bowman,  however,  relates 
one  case  in  his  private  practice  in  which  he  performed 
this  operation  with  most  marked  success.  The  ulcer, 
which  had  before  resisted  all  treatment,  at  once  took  on 
a  healing  action,  and  soon  cicatrized. 

Chronic  Vascular  Ulcer  of  the  Cornea. — This  name 
has  been  applied  to  what  is  generalh'  rather  a  vascular 
nebula  than  an  ulcer.  It  is  the  remains  of  an  ulcer  which 
has  become  filled  in,  but  in  which  the  vessels  originally 
destined  for  its  repair  have,  from  some  cause,  become  sta- 
tionary, and  by  their  presence  keep  the  eye  in  a  state  of 
constant  irritation. 

Sijmpfoms. — Continued  irritability  of  the  eye,  with 
lachrymation  and  dread  of  light  varying  in  intensit}',  but 
never  entirely  absent.  The  historj-  is  generally  that  of 
an  ulcer  of  the  cornea  which  had  recovered  up  to  a  cer- 
tain period,  from  w  hich  date  the  eye  had  ceased  to  mend, 
and  had  since  been  more  or  less  irritable.  On  examina- 
tion, a  small  nebula  will  be  seen  on  the  cornea  at  a  short 
distance  from  its  margin,  with  one  or  more  vessels — some- 
times a  regular  bundle  of  them — running  up  to  it  from 
the  sclerotic  adjoining  the  corneal  edge.  It  frequently 
happens  that  the  patient  has  been  under  treatment  for 
many  months,  and  sometimes  even  for  two  or  three  j'ears, 
during  which  time  he  has  persistently  dropped  drops  into 


FISTULA    OF    THE    CORNEA.  65 

tlie  eye,  both  stimulating  and  sedative  in  turn,  but  with- 
out gaining  the  slightest  benefit  from  either. 

Treatment. — Omit,  for  a  time,  all  applications  to  the 
eye,  and  insert  a  double  silk  thread  seton  into  the  skin 
of  the  temple.  The  seton  should  be  placed  so  high  on 
the'  side  of  the  temple  as  to  be  almost  amongst  the  short 
hairs,  as  there  will  then  be  no  noticeable  cicatrices  from 
the  ulceration  at  the  points  of  ingress  and  egress  of  the 
thread.  Care,  also,  should  be  taken  to  avoid  wounding 
the  branch  of  the  temporal  artery,  which  is  in  this  lo- 
cality. The  seton  should  be  worn  for  about  three  or  four 
weeks,  but  it  may  be  continued  longer  if  it  acts  benefi- 
cially on  the  e3'e,  and  does  not  excite  too  great  an  irrita- 
tion. In  conjunction  with  the  seton,  other  remedies  may 
be  tried.  The  lids  of  the  attected  eye  may  be  kept  closed, 
and  a  compress  bandage  (F.  2)  applied  over  them,  so  as 
to  give  the  e3"e,  for  a  time,  absolute  rest ;  or,  if  the  patient 
should  find  the  compress  hot  and  uncoiufortable,  it  may 
be  given  up,  and  a  cool  lotion  (F.  35,  3*7),  or  iced  water, 
or  a  cold  douche  may  be  used,  with  the  lids  closed,  three 
or  four  times  daily.  The  state  of  the  patient's  health 
should  be  carefulh'  looked  after,  and  any  irregularity 
should  be  corrected.  In  order  to  give  the  treatment 
every  possible  chance  of  success,  the  patient  should,  if 
his  circumstances  will  permit  of  it,  abstain  from  all  work 
with  the  sound  eye,  and  enjoy,  for  three  or  four  weeks, 
rest  with  recreation. 

A  Fistula  or  the  Cornea  is  a  small  opening  in  the 
cornea  which  has  little  or  no  tendenc}^  to  close,  and 
through  which  the  aqueous  humor  is  constantly  oozing. 

Causes. — 1st.  A  perforating  ulcer  of  the  cornea,  which 
from  some  cause  has  been  imperfectly  healed. 

2d.  A  contused  or  lacerated  wound  of  the  cornea,  after 
which  there  has  not  been  perfect  union. 

6* 


66  DISEASES    OF   THE    CORNEA. 

3d.  A  wound  of  the  cornea  with  wound  of  the  lens. 
The  swollen  lens  pressing  on  the  iris  may  keep  up  such 
constant  irritation  of  the  eye,  as  to  retard  the  union  of 
the  edges  of  the  corneal  wound. 

4th.  A  glaucomatous  state  of  the  eye  following  a  per- 
forating wound  of  the  cornea. 

5th.  The  presence  of  a  foreign  body  within  the  eye ; 
the  wound  through  which  it  entered  having  failed  to 
completely  unite. 

Si/mptoms. — A  shallow  or  scarcely  perceptible  anterior 
chamber,  with  a  minute  oj^ening  in  the  cornea,  through 
which  drops  of  the  aqueous  humor  may  be  seen  to  exude. 
One  useful  method  of  diagnozing  a  fistula  of  the  cornea 
is,  to  separate  the  eyelids  with  the  fingers  from  the  globe, 
and,  having  dried  the  suspected  spot  of  the  cornea  with 
a  piece  of  blotting-paper,  to  notice  if  the  surface  again 
becomes  moist  whilst  the  e^^e  is  kept  open. 

Treatment. — When  dependent  on  a  perforating  ulcer, 
or  a  wound  of  the  cornea,  the  fistulous  orifice  maj'  be 
touched  with  nitrate  of  silver.  This  is  best  applied  by  a 
fine  camel's-hair  brush,  which  has  been  first  moistened 
with  a  little  water,  and  then  drawn  a  few  times  across  a 
stick  of  nitrate  of  silver.  This  application  may  be  re- 
peated three  or  four  times,  at  intervals  of  two  days,  if  it 
does  not  excite  undue  inflammation.  If  this  treatment 
should  fail,  an  iridectomy  should  be  performed  ;  the  spot 
at  which  it  is  made  is  not  of  much  consequence,  as  in 
any  part  it  will  equall}^  succeed  in  promoting  the  closure 
of  the  fistula. 

When  the  fistula  is  due  to  a  cataractous  lens  pressing 
on  the  iris,  and  by  the  irritation  it  excites  preventing  the 
perfect  union  of  the  corneal  wound,  the  lens  should  be 
removed.  If,  however,  the  maintenance  of  the  fistula  is 
caused  by  a  glaucomatous  state  of  the  eye,  an  iridectoni}' 
should  be  made.     Lastl}',  if  all  other  means  have  failed, 


CLOUDINESS    OF    THE    CORNEA.  67 

the  edges  of  the  fistula  may  be  pared  with  a  broad  needle, 
and  united  by  a  single  fine  silk  suture. 

Nebula  or  Cloudiness  of  the  Cornea  may  be  caused 
by  inflammation  or  superficial  ulceration  of  the  cornea, 
or  by  an  injury  which  has  induced  a  traumatic  corneitis. 
It  may  be  limited  to  a  portion  of  the  cornea,  or  it  may  be 
irregularly  diffused  over  its  whole  surface.  In  some 
cases  the  nebula  is  due  to  an  interstitial  deposit  of  lymph 
in  the  true  corneal  tissue  ;  whilst,  in  other  instances,  it 
is  produced  by  a  layer  of  fine  semitransparent  cicatricial 
tissue,  formed  during  the  healing  process  of  a  superficial 
ulceration. 

Treatment. — When  the  eye  is  free  from  all  irritation, 
some  mild  stimulating  application  will  occasionally  do 
good,  by  exciting  the  absorbents  of  the  cornea  to  an  in- 
creased activity ;  but  there  are  no  specific  remedies  for 
the  cure  of  nebula.  The  applications  from  which  I  have 
found  the  most  benefit  are  the  following : 

1.  Lotio  hydrarg.  perchlorid  (F.  46).  Two  or  three 
drops  to  be  dropped  into  the  eye  twice  a  da}^  This 
remedy  is  often  a  powerful  irritant,  and  should  be  dis- 
continued if  the  eye  becomes  inflamed  or  painful. 

2.  Guttae  ol.  terebinth,  cum  ol.  oliv;e  (F.  23).  At  first 
these  drops  should  be  used  very  weak,  but  their  strength 
may  be  increased  if  the  eye  is  tolerant  of  them. 

3.  Dusting  calomel  into  the  eye  every  or  every  other 
day  for  a  short  time. 

4.  Guttae  zinci  sulphatis  (F.  20),  or  ziuci  chlorid  (F. 
19)  may  be  prescribed. 

5.  A  solution  of  the  iodide  of  potassium  (F.  18)  dropped 
twice  a  day  into  the  eye  is  thought  by  many  to  do  good. 

6.  Sulphate  of  soda.  Mr.  Powers  speaks  favorably  of 
the  general  results  he  has  obtained  from  the  use  of  this 
drug  in  corneal  opacities.     He  says  that,  "  in  the  employ  - 


68  DISEASES    OF   THE    CORNEA. 

ment  of  this  salt,  the  quantity  that  should  be  introduced 
at  one  time  into  the  eye,  should  not  exceed  one  or  two 
grains,  and  the  most  convenient  mode  of  application  con- 
sists in  everting  the  upper  lid,  and  brushing  the  powder 
lightl}^  over  the  surface  with  a  camel's-hair  brush."  * 

T.  The  late  Dr.  Mackenzie,  of  Glasgow,  recommended 
the  vapor  of  hydrocyanic  acid.f 

Leucoma  of  the  Cornea. — A  leucoma  is  a  dense  white 
opacity  of  the  cornea,  caused  by  a  loss  or  destruction  of 
a  part  of  its  substance,  the  gap  thus  made  being  replaced 
by  cicatrix  tissue,  which  is  opaque  and  white,  instead  of 
transparent  and  colorless  like  healthy  cornea.  It  may 
be  the  result  of  an  injury,  but,  more  frequently,  it  is  oc- 
casioned b}'  inflammation  and  deep  ulceration  induced  by 
other  causes.  It  is  irremediable.  With  the  leucoma 
there  is  often  some  alteration  in  the  shape  of  the  pupil, 
from  a  portion  of  the  iris  having  become  adherent  to  the 
cicatrix.  In  such  cases  the  ulcer,  which  had  caused  the 
leucoma,  had  penetrated  the  cornea,  and  the  iris  had 
either  been  dragged  into  the  wound  as  the  aqueous  es- 
caped, or  else,  falling  forwards,  had  contracted  adhesions 
to  the  granulations,  which  were  afterwards  to  be  con- 
verted into  the  cicatrix  tissue. 

One  of  the  evils  which  frequently  results  from  a  leu- 
coma is,  that  the  normal  curvature  of  that  portion  of  the 
cornea  which  remains  transparent,  is  changed  in  one  or 
more  of  its  meridians,  and  the  eye  rendered  astigmatic ; 
a  defect  which  may  be  neutralized,  to  a  great  extent,  by 
a  properly-fitted  cylindrical  glass. 

*  Power  on  Sulphate  of  Soda  for  removing  Opacities  from  the 
Cornea.     The  Practitioner,  vol.  i,  p.  155. 

f  Mackenzie  on  the  Diseases  of  the  E^^e,  4th  edition,  pp.  639 
and  428. 


CONICAL   CORNEA.  69 

Opacity  of  the  Cornea  from  Lead  is  caused  b}-  the 
use  of  a  lead  lotion  when  the  cornea  is  ulcerated  or 
abraded  ;  the  lead  is  deposited  on  the  surface 
as  a  carbonate,  producing  a  milky-white  patch, 
which  is  often  sufficiently  opaque  to  occlude 
either  the  portion  of  iris  or  the  pupil  which  lies 
behind  it. 

The  treatment  consists  in  removing  the  la3-er 
of  lead  deposit  which  has  coated  the  abraded 
surface  of  the  cornea.  This  may  be  done  with  a 
small  knife  curved  convexly  on  it.s  cutting  edge, 
as  in  Fig.  1.  The  lids  being  separated  b}^  a 
speculum,  the  operator  with  one  hand  fixes  the 
eye  with  a  pair  of  forceps,  whilst  with  the  other 
he  gently  scrapes  the  whitened  surface  of  the 
cornea,  until,  having  detached  the  epithelium, 
he  comes  down  to  the  thin  coating  of  lead;  steadily  but 
gentl}'  scraping,  he  will  generally  succeed  in  detaching 
all  that  is  required.  Having  completed  the  operation,  a 
few  drops  of  olive  oil  should  be  dropped  into  the  63^6,  and 
a  fold  of  wet  lint  laid  over  tlie  closed  lids. 

Conical  Cornea  is  a  staphylomatous  bulging  of  the 
middle  portion  of  the  cornea,  caused  by  a  thinning  of 
that  structure  in  its  central  region.  The  disease  comes 
on  very  imperceptibly,  and  progresses  without  pain.  It 
first  manifests  itself  to  the  patient  by  a  change  in  the 
focus  of  the  eye,  which  becomes  irregularly  myopic ;  and 
this  defect  grows  worse  as  the  bulge  increases,  until,  in 
severe  cases,  the  sight  is  so  much  impaired  as  to  render 
the  eye  almost  useless.  Usually  there  is  no  undue  vas- 
cularity of  the  globe,  but,  in  some  instances,  where  the 
conicity  is  rapidly'  advancing,  there  is  slight  ciliary  red- 
ness. After  the  cone  has  attained  a  certain  size,  its  ajiex 
loses  its  transparency  and    becomes  nebulous  or  semi- 


70  DISEASES    OF   THE    CORNEA. 

opaque,  with  its  epithelial  surface  roughened.  One  or 
hoth  eyes  may  be  affected ;  but,  when  both  are  involved, 
the  conicity  is  generally  much  greater  in  one  eye  than 
the  other. 

The  disease  will  frequently  advance  rapidl}"  in  one  eye, 
whilst  it  remains  stationary  in  the  other. 

Biagnotiis. — In  the  advanced  stage,  conical  cornea  is 
easily  recognized,  but,  at  the  commencement  of  the  dis- 
ease, it  is  often  difficult  to  diagnose,  and  its  presence 
may  be  easily  overlooked.  The  cornea  is  best  examined 
by  looking  at  the  eye  from  its  outer  side,  so  as  to  see  the 
cone,  if  one  exists,  in  profile.  In  a  paper  by  Mr.  Bow- 
man, on  "  Conical  Cornea,"  in  the  Royal  London  Oph- 
thalmic Hospital  Reports,  vol.  ii,  he  saj'S  :  "  Soon  after 
the  immortal  invention  of  Helmholtz,  I  found  the  oph- 
thalmoscope very  useful  in  detecting  slight  degrees  of 
conical  cornea.  For  this  purpose  the  concave  mirror 
only  is  to  be  used  without  a  convex  lens.  On  turning 
the  mirror  so  as  to  throw  light  at  different  angles,  the 
side  of  the  cone  opposite  to  the  light  is  darkened." 

In  speaking  of  conical  cornea,  Bonders  remarks :  "  High 
degrees  strike  the  eye  at  once.  Slight  degrees,  on  the 
contrary,  are  often  enough  overlooked.  The  disturbance 
of  the  power  of  vision  frequently  suggests  the  idea  of 
amblyopia  combined  with  myopia."  ....  Further  on, 
he  recommends  the  use  of  the  ophthalmoscope  as  a  means 
of  diagnosis  in  slight  cases  of  conical  cornea,  and  ob- 
serves that,  "  in  the  inverted  image  where  there  is  a  tol- 
erably wide  pupil,  we  overlook  at  the  same  time  a  rather 
large  portion  of  the  fundus  oculi ;  the  image,  therefore, 
of  one  part  or  other,  for  example,  of  the  optic  disc,  re- 
mains in  the  field  of  vision,  both  on  moving  the  head  of 
the  oltserver  and  on  shifting  the  lens  before  the  observed 
eye.  At  the  same  time,  however,  the  raj's  which,  pro- 
ceeding from  the  optic  disc,  strike  the  eye  of  the  ob- 


CONICAL   CORNEA,  71 

server,  pass  each  time  tlirougli  other  parts  of  the  cornea. 
Now,  if  its  curvature  is  irregular,  the  result  is,  that  the 
form  of  the  disc  each  time  alters,  it  shortens  in  this  di- 
rection, extends  in  that  direction,  and,  moreover,  is  never 
seen  acutely  in  its  integrity."* 

Pathology  of  Conical  Cornea. — It  is  very  difficult  to  as- 
cribe any  cause  for  the  structural  changes  in  the  cornea 
which  give  rise  to  the  staphylomatous  bulging.  The  ten- 
sion of  such  eyes  is  seldom,  if  ever,  in  excess  ;  indeed,  it 
is  more  frequent  to  find  them  slightly  soft.  All  that  we 
ai'e  at  present  able  to  sa}^  of  conical  cornea  is,  that  from 
some  cause,  possibly  failing  nutrition,  the  central  portion 
of  the  cornea  becomes  thinned  and  its  power  of  resist- 
ance diminished,  so  that  it  yields  before  the  normal  pres- 
sure from  within  the  eye,  and  bulges  conically.  The  bulg- 
ing may  increase  until  the  apex  of  the  cone  seems  to  be 
on  the  verge  of  bursting,  but  this  is  an  accident  which 
seldom,  if  ever,  occurs  spontaneously.  Mr.  Bowman 
thinks  that  this  fact  may  be  thus  explained :  "  As  the 
cornea  becomes  thinner,  the  escape  of  the  aqueous  humor 
by  exosmose  is  facilitated,  and  thus  the  internal  pressure 
is  reduced  so  as  to  be  no  longer  in  excess  of  the  dimin- 
ished resisting  power  of  the  cornea." 

The  following  is  an  account  of  a  microscopical  exami- 
nation made  by  Mr.  Hulke,  of  a  conical  cornea  taken 
from  an  eye  which  had  been  excised  by  Mr.  Bowman 
during  an  operation  for  the  removal  of  a  large  sebaceous 
cyst  from  the  orbit : 

"  The  central  conical  nebulous  portion  was  much  thin- 
ner than  the  transparent  periphery  of  the  cornea,  where 
the  curve  was  natural.  This  thinning  began  at  the  base 
of  the  cone,  and  progressively  increased  towards  the  apex, 

*  Di-inders  on  the  Accommodtition  aiul  Refraction  of  the  Eye, 
pp.  550-551. 


72  DISEASES   OF   THE    CORNEA. 

where  it  reached  its  niaximuni.  At  this  point  tlie  mean 
depth  of  several  vertical  sections  was  only  one-third  of 
that  of  the  ])eripheral  region.  The  continnity  of  the  an- 
terior elastic  lamina  was  perfect,  but  upon  the  cone  this 
structure  was  much  thinner  than  elsewhere,  and  wrinkled ; 
it  was  underlaid  by  a  stratum  of  crowded,  elongated, 
club-like  nuclei,  and  beneath  these  the  normal  lamellar 
tissue  was  placed  by  a  web  of  caudate  and  nuclear  fibres, 
amongst  the  meshes  of  which  clusters  of  large  oval  and 
fusiform  cells  were  packed.  The  structure  of  the  ti'ans- 
parent  peripheral  region  was  perfectly  normal,  and,  at 
the  base  of  the  cone,  there  was  a  gradual  transition  from 
the  healthy  to  the  diseased  tissue,  the  interlamellar  cor- 
puscles becoming  more  plentiful,  branched,  and  drawn 
out  into  fibres,  which,  in  many  instances,  coalesced  with 
those  from  neighboring  corpuscles.  The  posterior  elastic 
lamina  and  the  epithelium,  both  on  the  front  and  on  the 
back  of  the  cornea,  were  unchanged." 

"  The  changes  I  have  described,"  adds  Mr.  Hulke, 
"  were  confined  to  the  laminated  tissue  of  the  cornea  and 
the  anterior  elastic  lamina.  The  substitution  of  a  web  of 
nuclear  fibres  and  cells  for  the  regular  lamination  of  the 
cornea,  explains  the  nebulosity  of  the  cone  and  the  lia- 
bility to  bulge."* 

Treatment.  —  When  conical  cornea  is  in  its  earliest 
stage,  it  is  possible,  that  by  judicious  prophylactic  treat- 
ment, its  progress  may  be  retarded ;  but,  when  the  cone 
is  steadily  advancing,  I  know  of  no  help  except  by  opera- 
tion which  is  likely  to  be  of  any  avail. 

A)^  preventive  treatment,  all  work  Avhich  strains  or 
reddens  the  e^'es  should  be  avoided.  The  cold  or  tepid 
douche,  whichever  is  the  more  pleasant,  may  be  used 
three  or  four  times  dail3\     When  there  is  axiy  ciliarj^  red- 

*  Koyiil  London  Opbtluihnic  Ilosjntal  Keports,  vol.  ii,  j).  154. 


CONICAL    CORNEA.  73 

ness,  two  or  three  leeches  ma}'  be  advantageously  applied 
to  the  temple.  If  the  patient  is  feeble,  tonics  of  quinine, 
iron,  «fec.,  should  be  ordered.  Except  in  the  very  com- 
mencement of  the  disease,  but  little,  if  any,  benefit  will 
be  derived  from  either  concave,  spherical,  or  cylindrical 
glasses.  The  astigmatism  produced  by  the  conicity  is  so 
irregular  that  it  cannot  be  sufficiently  corrected  by  lenses 
to  afford  much  improvement  of  sight.  Occasionally  a 
stenopaic  slit  placed  behind  a  concave  spherical  lens  is 
found  of  decided  service,  and,  when  this  is  the  case,  the 
patient  may  be  provided  with  similar  spectacles,  but  with 
the  understanding  that  they  must  be  laid  aside  if  they 
fatigue  the  eyes. 

Operative  Tr-eatment. — 1.  To  better  the  sight  of  the 
palieut,  the  position  of  the  pupil  must  be  so  changed 
that  it  is  brought  opposite  to  that  portion  of  the  cornea 
which  is  the  least  affected  b}^  the  conicity. 

2.  To  arrest  the  progress  of  the  disease,  it  is  desirable 
to  slightly  lessen  the  tension  of  the  eye,  so  as  to  compen- 
sate for  the  diminished  resisting  power  of  the  cornea. 
When  this  is  satisfactorily  accomplished,  the  cone  will 
cease  to  increase,  and  in  some  of  the  recorded  cases  it 
has  actually  receded. 

Mr.  Bowman  first  suggested  the  making  a  slit-shaped 
pupil  by  performing  the  operation  of  iridodesis  twice  in 
the  same  eye,  but  at  an  interval  of  several  daj's.  He  first 
drew  a  piece  of  the  iris  downwards  and  tied  it,  and  after 
a  few  da3's  he  repeated  the  operation  in  the  upward  di- 
rection, and  fastened  it  in  a  similar  manner,  thus  convert- 
ing the  pupil  into  a  vertical  slit.  (See  Operation  of 
Iridodesis.)  The  improvement  which  followed  the  first 
iridodesis  was  very  decided,  but  that  which  ensued  after 
the  second  was  very  doubtful.  I  have  done  this  oi^era- 
tion  several  times,  but  found  no  increased  benefit  from 
the  second  iridodesis.     Von  Graefe  has  for  a  long  time 

7 


74  DISEASES    OF   THE    CORNEA. 

practised  iridectomy  for  the  relief  of  conical  cornea,  with 
the  view  of  lessening  the  tension  of  the  e^e,  whilst,  at 
the  same  time,  he  altered  the  position  of  the  pupil.  The 
success  which  has  followed  this  mode  of  treatment,  has 
induced  Mr.  Bowman  to  adopt  it  in  preference  to  his  own 
operation.  The  iridectomy  should  be  made  rather  small, 
and  either  directly  upwards,  or  upwards  and  inwards, 
unless  special  circumstances  call  for  it  in  a  different 
position.  The  defoi-mity  of  the  pupil  will  be  then  so 
covered  by  the  upper  lid  as  to  be  scarcely  noticeable. 

Von  Graefe  has  lately  adopted  a  new  operation  for  the 
relief  of  conical  cornea.*  It  consists  in  the  establishing 
an  ulceration  on  the  apex  of  the  cone  wuth  a  view  to  its 
producing  a  general  flattening  of  the  cornea  by  the  con- 
traction which  always  accompanies  the  cicatrization  of 
the  wound.  The  operation  is  as  follows:  The  patient 
having  been  placed  under  chloroform,  and  the  lids  sep- 
arated b}'  a  spring  speculum,  a  small  flap  of  about  one 
line  in  width  is  to  be  made  with  a  fine  cataract  knife 
through  the  superficial  la3ers  of  the  cone,  taking  care 
that  the  point  of  the  instrument  does  not  penetrate  the 
anterior  chamber.  Should  this  accident  happen,  the 
operation  must  be  at  once  stopped  and  postponed  to  a 
future  da^^  The  flap  of  cornea  is  now  to  be  seized  with 
a  pair  of  forceps  and  cut  off  with  a  pair  of  scissors.  On 
the  following  day  the  cut  surface  is  to  be  gently  touched 
Avith  the  diluted  nitrate  of  silver  (F.  5),  and  this  applica- 
tion is  to  be  repeated  every  two  or  three  days  until  an 
ulcer  with  some  surrounding  corneal  haze  is  produced. 
Tlie  e3'e  is  now  to  be  kept  closed  with  a  compress  and 
bandage  until  the  ulcer  has  healed.  A  solution  of  atro- 
pine (F.  13)  should  be  dropped  dail^'  into  the  eye  to  keep 
the  pupil  dilated  and  allay  irritation.     During  the  healing 

*  Archiv  fur  Oplithahnologie,  vol.  xii,  2,  215. 


KERATO-GLOBUS.  75 

of  the  ulcer,  a  general  contraction  of  the  surrounding 
cornea  takes  place  towards  the  cicatrix,  and  the  conicity 
is  thus  sensibly  diminished. 

If  the  leucoma,  which  is  thus  produced,  should  so  oc- 
clude the  pupil  as  to  interfere  with  sight,  a  new  pupil 
should  be  made  by  a  small  iridectomy  opposite  to  that 
portion  of  the  cornea  which  presents  the  most  normal 
curvature. 

Kerato-globus — Hydrophthalmia — is  a  uniform  en- 
largement of  the  anterior  half  of  the  globe,  which  often 
attains  to  such  dimensions  as  to  prevent  the  lids  from 
closing  over  it.  Both  eyes  are  usually  affected,  although 
one  may  be  more  seriously  involved  than  the  other.  It 
is  sometimes  congenital,  and  may  possibly  be  due  to  some 
hereditary  s^q^hilitic  taint;  but  it  may  also  come  on  after 
corneitis.  It  most  frequently  occurs  in  young  children. 
The  peculiar  amazed  stare  which  this  deformity  of  the 
eyes  gives  to  the  patient  is  very  unsightly.  The  cornea 
will  sometimes  be  seen  of  almost  double  its  normal  pro- 
portion. In  some  cases  it  is  slightly  cloudy,  whilst  in 
others  its  transparency  is  unimpaired.  The  adjacent 
sclerotic  is  thinned  and  of  a  bluish  color  from  the  subja- 
cent choroid  shining  through  it.  The  anterior  chamber 
is  large  and  deep,  and  the  iris  is  pushed  backwards,  fre- 
quently tremulous,  and  so  greatly  stretched  that  its 
ciliary  attachment  is  occasionally  drawn  within  the  ante- 
rior chamber.  The  pupil  is  usually  rather  dilated  and 
sluggish,  and  sometimes  oval  or  pear-shaped.  The  sight 
is  always  very  defective,  and  in  the  worst  cases  com- 
pletely destroyed.  The  disease  is  usually  slowly  progres- 
sive. 

Treatment. — Unless  the  disease  is  steadily  increasing, 
and  the  sight  diminishing,  I  believe  it  is  best  to  leave 
h^'drophthalmic  eyes  alone.     Their  powers  of  repair  are 


7(3  DISEASES    OF    THE    CORNEA. 

enfeebled,  and  they  stand  operations  badly.  I  have  cer- 
tainly seen  an  iridectomy  occasionally  do  good,  bnt,  on 
the  other  hand,  I  have  seen  cases  in  which  it  did  yjositive 
harm.  Stenopaic  spectacles  may  be  tried,  and,  if  they 
improve  the  sight,  they  may  be  worn.  If  one  eye  is  quite 
blind,  and  suffering  from  not  being  fully  protected  b}'  the 
lids,  it  may  be  excised. 

A  Staphyloma  of  the  Cornea  is  a  projecting  for- 
wards or  bulging  of  the  Avhole  or  a  i)art  of  the  cornea,  or 
of  the  new  tissue  which  supplies  its  place  when  a  part  or 
the  whole  of  it  has  been  destro^'cd  by  injury  or  disease. 

A  staphyloma  of  the  cornea  may  be  either  partial  or 
complete;  that  is  to  saj^,  it  maybe  limited  to  a  small  por- 
tion, or  it  may  involve  the  whole  of  the  cornea  or  the  new 
structure  which  re2)resents  it. 

Partial  Staphyloma  or  the  Cornea. — When  a  por- 
tion of  the  cornea  has  been  destroyed  by  sloughing  or 
ulceration,  its  place  is  made  good  by  cicatricial  tissue, 
which  is  more  or  less  white  and  opaque,  and  in  many 
cases  incapable  of  resisting  the  normal  outward  pressure 
of  the  parts  within  the  e3'e.  Slowly  yielding,  it  bulges 
and  forms  an  unsightl}^  prominence  on  the  cornea. 

Treatment. — The  objects  to  be  accomplished  are,  1st, 
to  arrest  the  progress  of,  and,  if  possible,  to  diminish  the 
bulge;  and,  2d,  to  restore  some  of  the  lost  sight  to  the 
eye.  Both  of  these  conditions  may  be  often  attained  by 
the  operation  of  iridectomy. 

The  removal  of  a  piece  of  the  iris  by  iridectom}'  exer- 
cises an  important  influence  in  diminishing  the  tension 
of  the  globe,  and  thus  frc(iuently  prevents  any  further 
increase  of  the  staphyloma;  and  in  a  few  instances  which 
have  come  under  my  notice,  the  bulging  has  decidedly 
receded.     But,  in  addition  to  this,  by  the  excision  of  a 


STAPHYLOMA.  77 

portion  of  the  iris  opposite  to  that  part  of  the  cornea 
which  is  in  the  most  healthy  state,  an  artificial  pupil  is 
made ;  and  if  the  fundus  of  the  e}"e  is  sound,  and  the 
transparency  and  curvature  of  the  cornea  opposite  the 
new  pupil  tolerabl}^  good?  useful  sight  will  be  regained. 

Complete  Staphyloma  of  the  Cornea  is  a  bulging 
of  the  entire  structure  which  has  replaced  the  original 
cornea  after  it  has  been  destroyed  b}^  ulceration  or  slough- 
ing. 

Progress  of  the  Disease. — After  the  loss  of  the  cornea, 
the  exposed  surface  of  the  iris  is  soon  coated  with  a  film 
of  lymph.  This  becomes  organized  and  ultimately  con- 
verted into  a  bluish-white  cicatricial  tissue,  to  which  the 
iris  is  firmlj^  adherent.  The  eye  will  now  either  gradually 
shrink,  or  the  new  tissue  will  yield  before  the  pressure 
from  within  and  become  staplndomatous. 

Treatment  of  Commencing  Stajjhyloma If  the  patient 

is  seen  early,  the  first  object  in  view  is  to  prevent  the 
formation  of  the  staphyloma,  and  this  is  best  accom- 
plished by  the  removal  of  the  lens,  if  it  has  not  already 
escaped  from  the  eye.  After  the  slough  of  the  cornea 
has  separated,  the  lens  will  be  often  seen  Ijing  in  the 
centre  of  the  pupil,  perfectly  transparent  and  projecting 
slightly  forwards.  It  may  then  be  removed  by  gently 
lifting  it  away  with  the  point  of  a  fine  needle. 

If  the  eye  is  not  seen  until  a  later  period,  but  when 
the  staphylomatous  bulging  is  still  recent,  and  the  new 
tissue  which  occupies  the  corneal  space  is  yet  but  imper- 
fectly formed,  the  plan  recommended  by  Mr.  Bowman 
for  the  removal  of  the  lens  may  be  adopted.  A  broad 
needle  is  passed  through  the  most  prominent  part  of  the 
staphyloma  in  the  direction  of  the  lens,  so  as  to  penetrate 
its  capsule,  and  the  lenticular  matter  is  freely  broken  up. 
The  needle  is  then  withdrawn,  and  through  the  aperture 


78  DISEASES    OF    THE    CORNEA. 

it  has  made  a  curette  is  introduced,  and  as  much  of  the 
leus  matter  as  is  sufficiently-  soft  and  diffluent,  is  allowed 
to  escape  from  the  eye  along  its  groove.  The  puncture 
made  with  the  broad  needle  ma}'  be  repeated  every  two 
or  three  days  until  the  prominence  of  the  staphyloma  is 
reduced. 

Treatment  of  Complete  Staphyloma  of  the  Cornea. — 
The  eye  being  lost  for  all  visual  purposes,  the  object  to 
be  accomplished  is  to  get  rid  of  the  unsightly  staphy- 
lomatous  bulging,  and  to  enable  the  patient  to  wear  an 
artificial  ej'c.  One  of  the  following  modes  of  treatment 
ma}^  be  adopted :  1st.  The  staphjlomatous  eye  may  be 
excised.  2d.  The  staphyloma  ma^'  be  abscissed.  3d. 
The  staph3'loma  may  be  treated  by  seton. 

1st.  The  Staph i/lomatou.-<  Eye  may  he  excised. — When 
the  bulging  is  large  and  unsighth',  and  causes  the  patient 
annoyance  from  the  obstruction  it  offers  to  the  free  move- 
ments of  the  lids  over  it,  and  there  is  reason  to  believe 
that  the  fundus  of  the  e^'e  is  laihealthy,  this  is  the  best 
operation.  The  patient  will  recover  from  it  more  quickly 
than  from  any  other,  all  chance  of  future  troulile  is 
avoided,  and  an  artificial  e3e  can  be  worn,  although  the 
deception  may  not  be  quite  so  complete  as  after  a  suc- 
cessful case  of  abscission  of  the  staphyloma. 

2d.  The  Staphyloma  may  be  abscissed. — There  are  two 
modes  of  thus  dealing  with  a  staphyloma. 

a.  The  bulging  portion  may  be  simply  abscissed,  and 
the  sclerotic  wound  be  left  to  close  by  granulation. 

/?.  The  staphyloma  may  be  abscissed,  and  the  edges  of 
the  wound  of  the  sclerotic  be  brought  together  by  su- 
tures, after  the  manner  recommended  b}'  Mr.  Critchett. 

(a.)  For  the  simple  abscission  of  the  staphyloma,  the 
lids  should  be  first  separated  by  a  spring  speculum,  and 
a  puncture  made  w-ith  a  broad  needle  at  its  margin,  suf- 
ficiently large  to  admit  one  blade  of  a  pair  of  scissors, 


STAPHYLOMA.  79 

when,  with  a  few  snips  around  its  circumference,  the 
whole  of  tlie  bulging  portion  is  removed.  Another  way 
of  abscissing  the  staph^-loma  is,  to  transfix  its  base  with 
a  Beer's  knife,  and  first  cutting  through  its  upper  half, 
then  to  seize  hold  of  the  detached  portion  with  a  pair 
of  forceps,  and  complete  the  abscission  of  the  remaining 
segment,  either  with  the  kuife  or  with  a  pair  of  scissors. 
The  speculum  is  then  to  be  removed,  and  a  pad  of  cotton- 
wool to  be  applied  firml}'  with  a  bandage  over  the  closed 
lids. 

(i?.)  Mr.  Critchett's  operation  for  abscission  of  the  sta- 
phyloma was  first  described  by  him  in  the  first  chapter 
of  vol.  iv,  of  the  "  Ro^al  London  Ophthalmic  Hospital 
Reports."     The  following  is  a  brief  abstract : 

"  The  patient  being  placed  under  the  influence  of 
chloroform,  the  staphyloma  is  freely  exposed  by  means 
of  a  wire  speculum  ;  a  series  of  four,  or  rather  five,  small 
needles,  with  a  semicircular  curve,  are  passed  through 
the  mass  about  equidistant  from  each  other,  and  at  such 
points  as  the  lines  of  incision  are  intended  to  traverse. 

"  These  needles  are  left  in  this  position,  with  both  ex- 
tremities protruding  to  an  equal  extent  from  the  staphy- 
loma. 

"  The  next  stage  of  the  proceeding  is  to  remove  the 
anterior  part  of  the  staphyloma. 

"  M}'  usual  plan  is  to  make  an  opening  in  the  sclerotic, 
about  two  lines  in  extent,  just  anterior  to  the  tendinous 
insertion  of  the  external  rectus,  with  a  Beer's  knife.  Into 
this  opening  I  insert  a  pair  of  small  probe-pointed  scis- 
sors, and  cut  Oiit  an  elliptical  piece  just  within  the  points 
where  the  needles  haA'e  entered  and  emerged.  The 
needles,  armed  with  fine  black  silk,  are  then  drawn 
through,  each  in  its  turn,  and  the  sutures  are  carefully 
tied,  so  as  to  approximate  as  closely  as  possible  the  di- 
A'ided  edges  of  the  sclerotic  and  conjunctiva.     The  opera- 


80  DISEASES   OF   THE    CORNEA, 

tion  is  now  finished ;  the  specuhim  may  be  removed  so 
as  to  allow  the  lids  to  close,  and  wet  lint  may  be  applied 
to  keep  the  parts  cool." 

Unless  this  operation  is  carefully  performed,  there  is 
apt  to  be  a  projecting  corner  at  one  or  both  of  the  ex- 
tremities of  the  cicatrix.  Such  a  result  is  a  serious  im- 
pediment to  the  proper  fitting  of  an  artificial  eye,  and 
may  require  a  second  operation  to  remedy  it. 

Abscission  of  the  staphyloma  should  never  be  per- 
formed where  there  is  reason  to  suspect  pre-existing  dis- 
ease of  the  choroid  or  retina,  as  deep  hemorrhage  is  likely 
to  follow  the  removal  of  the  front  of  the  globe,  which  may 
necessitate  the  immediate  excision  of  the  rest  of  the  eye. 

Treatment  of  Staphyloma  of  the  Cornea  by  Seton. — J'or 
the  purpose  of  reducing  the  bulge  of  the  staphyloma,  so 
that  an  artificial  eye  may  be  worn,  Von  Graefe  has  rec- 
ommended that  a  silk  thread  seton  should  be  passed 
through  the  staphyloma,  with  the  view  of  inducing  a  sup- 
purative inflammation,  and  a  subsequent  shrinking  of  the 
globe.* 

In  from  sixteen  to  thirty-six  hours  after  the  introduc- 
tion of  the  thread,  an  acute  suppurative  choroiditis  will 
be  set  up,  with  chemosis  and  enlargement  of  the  globe, 
and  the  seton  is  then  to  be  withdrawn.  The  acute  symp- 
toms will  gradually  subside  in  from  three  to  eight  days, 
and  atrophy  of  the  globe  will  shortly  follow. 

Ciliary  Staphyloma  —  Anterior  StajDhyloma  of  the 
Sclerotic — is  a  staphylomatous  projection  of  the  sclerotic 
in  the  ciliary  region  of  the  eye.  It  consists  of  a  series  of 
grape-like  bulgings,  with  such  a  thinning  of  the  sclerotic 
coat  that  the  dark  color  of  the  ciliar}^  processes  with 
which  it  is  in  contact  is  distinctly  seen  through  it.    It  may 

*  Archiv  fur  Oplitlial.  vol.  ix,  part  ii,  pp.  106-109. 


STAPHYLOMA.  81 

be  limited  to  a  part,  or  it  may  involve  the  whole  of  the 
ciliary  region  of  the  eye. 

Ciliary  stai)hyloma  may  be  the  result  of  disease  or  in- 
jur3^  In  the  majority  of  cases  it  is  dependent  on  a 
chronic  irido-choroiditis,  accompanied  with  a  gradual 
wasting  of  the  sclerotic  in  the  immediate  vicinity  of  the 
ciliary  processes,  so  that  it  loses  its  normal  power  of  re- 
sisting the  outward  pressure  from  within  the  eye,  and, 
slowly  yielding,  a  dark  irregular  nodulated  prominence 
is  developed.  As  the  direct  result  of  an  injuiy,  ciliary 
staphyloma  may  be  produced  by  a  rupture  of  the  scle- 
rotic, and  especially  when  there  is  also  associated  with  it 
an  extensive  prolapse  of  the  iris  and  choroid, 

Tlte  jjrognosis  of  ciliary  staphyloma  is  always  most  un- 
favorable ;  even  when  slight,  there  is  considerable  impair- 
ment of  vision  ;  but  the  danger  to  be  apprehended  is, 
that  it  will  increase,  and,  as  it  enlarges,  all  sight  will  be 
destroj-ed. 

Treatment. — When  a  ciliary  staphyloma  is  dependent 
on  disease,  no  matter  whether  it  has  originated  from  con- 
stitutional causes  or  from  some  remote  injury  to  the  eye, 
it  ma3'  frequently,  in  its  early  stages,  be  arrested  by  the 
operation  of  iridectomy.  It  is  the  only  remed}^  from 
which  I  can  really  feel  satisfied  that  I  have  seen  any  de- 
cided benefit ;  and,  although  in  some  cases  it  may  fail  in 
accomplishing  the  desired  end,  j-et  it  is  certainly  the  most 
successful  of  all  the  remedial  agents  I  have  known  prac- 
tised for  the  relief  of  this  disease.  By  reducing  the  ten- 
sion of  the  eye,  the  tendency  of  the  staphjdoma  to  in- 
crease is  certainly  diminished,  and,  in  some  instances, 
completely  stopped.  It  should  be  remembered  that,  even 
though  the  tension  of  the  eye,  at  the  time  of  the  opera- 
tion, may  be  normal,  yet  the  resisting  power  of  the  scle- 
rotic has  been  lowered  by  disease,  and  that,  by  lessening 


82  DISEASES  OF  tul:  cornea. 

the  tension  which  exists,  the  condition  of  the  e^'e  is  im- 
proved. 

If,  howeA'er,  the  ciliary  staphyloma  is  produced  hy  a 
rupture  of  the  sclerotic,  I  know  of  no  remedy.  The  sight 
which  such  an  eye  retains,  even  when  the  staphyloma  is 
small,  is  usually  ver}-  limited  ;  but,  if  the  bulging  is  suf- 
ficientl}'^  large  to  interfere  with  the  free  movements  of 
the  lid,  the  eye  is  generally  blind.  When  an  e3'e,  thus 
completel}^  lost  for  all  visual  purposes,  is  unseemly  in  ap- 
pearance and  troubles  the  patient,  the  best  treatment  is 
to  excise  it. 

Cyclitis,  or  inflammation  of  the  ciliary  body,  is  sel- 
dom an  independent  or  primar}-  atlection,  except  in  cases 
of  wounds  or  some  other  injury  in  the  vicinity  of  the 
ciliar}"  region  of  the  eye.  It  is  usiiall}'  produced  b}'  the 
inflammation  in  iritis  spreading  to  the  ciliary  bod}' ;  but 
it  ma}'  also  arise,  although  less  frequentl}',  from  an  ex- 
tension forwards  of  the  morbid  action  of  an  inflamed 
choroid.  Cyclitis,  like  iritis,  ma}'  be  either  plastic,  serous, 
or  suppurative,  according  to  the  character  of  the  inflam- 
mation of  which  it  is  the  continuance.  When,  however, 
it  is  excited  b}'  an  injury,  it  is  nsuall}'  either  serous  or 
suppurative.  The  injuries  which  are  most  liable  to  pro- 
duce cj'clitis,  are,  penetrating  or  incised  wounds  in  the 
ciliary  region,  the  lodgment  of  a  foreign  body  within  the 
eye,  a  dislocation  of  the  lens,  or  the  forcible  removal  of 
a  piece  of  opaque  capsule,  especially  if  during  the  opera- 
tion an}^  drag  has  been  made  on  the  ciliary  processes. 

Symptoms. — Pain  in  the  ciliary  region,  with  marked 
tenderness  on  pressure  ;  a  pinkish  zone  around  the  cornea 
from  distension  of  the  ciliary  vessels,  photophobia  and 
lachrymation,  and  turbidity  of  the  vitreous  from  inflam- 
matory exudations  into  it  from  the  ciliary  processes. 
After  wounds  in  the  ciliary  region,  large  masses  of  lymph 


CYCLITIS.  83 

or  pus  may  be  frequently  seen  with  the  unaided  eye, 
lying-  behind  and  to  one  side  of  the  lens.  The  iris  usu- 
ally participates  in  the  inflammation,  even  when  the  dis- 
ease originates  in  the  ciliary  body,  its  striae  become  in- 
distinct and  its  color  changed,  the  pupil  is  sluggish  or 
inactive,  and  posterior  synechiae  are  formed ;  tlie  aque- 
ous grows  serous  and  turbid,  and  there  is  frequentlj^  hy- 
popion.  The  sight  is  greatly  impaired,  and  the  tension 
of  the  globe  is  often  increased. 

Prognosis. — When  cyclitis  is  due  to  an  extension  of 
the  inflammation  from  the  iris,  it  will  probably,  under 
judicious  treatment,  subside ;  but  it  must  always  be  re- 
garded as  a  serious  complication  of  the  original  disease. 
When,  however,  it  arises  from  an  injury,  the  prognosis 
is  very  unfavorable.  If  the  inflammation  subsides  under 
treatment,  the  e3'e  generally  becomes  soft,  and  partially 
shrinks,  and  all  sight  is  destroyed.  The  great  danger, 
however,  to  be  feared,  is  lest  while  endeavoring  to  save 
the  injured  eye,  the  other  should  become  sympathetically 
aflfected. 

Treatment. — When  cyclitis  is  secondary  and  proceeds 
from  iritis  or  choroiditis,  the  treatment  recommended  in 
the  sections  devoted  to  these  diseases  must  be  followed. 
When,  however,  it  is  caused  by  an  injury,  no  special  me- 
dicinal treatment  will  be  of  service.  At  the  commence- 
ment of  the  attack,  leeches  should  be  applied  to  the  tem- 
ple, and  warm  belladonna  fomentations  (F.  8)  to  the  ej^e, 
and  in  the  intervals  between  the  applications  the  eye  may 
be  kept  at  rest  by  a  slight  compress  and  bandage.  If  this 
should  fail  to  give  relief,  a  fold  of  linen,  wet  with  the  bel- 
ladonna lotion,  may  be  laid  over  the  closed  lids.  The 
bowels  should  be  freely  acted  on  by  a  purgative,  and,  if 
the  pain  is  severe,  opiates  should  be  given  at  bedtime. 
The  strength  of  the  patient  must  be  maintained  b}^  a 
liberal  diet,  and  a  moderate  amount  of  stimulants  may  be 


84  DISEASES    OF   THE    CORNEA. 

allowed.  If  necessaiy,  tonics  of  quinine  or  bark  should 
be  prescribed.  The  results,  however,  of  cjclitls  proceed- 
ing from  injur}'  are  so  unfavorable,  both  as  respects  the 
injured  eye  and  the  risk  to  which  the  sound  one  is  exposed 
from  sj^mpathy,  that  if  the  inflammation  does  not  yield 
rapidly  to  treatment,  I  would  strongly  urge  the  removal 
of  the  globe,  and  this  especially'  if  the  accident  be  a 
wound  in  the  ciliar}^  region. 

Episcleritis  is  a  small  diffuse  swelling  beneath  the 
conjunctiva,  iisuallj'  on  the  temporal  side  of  the  cornea, 
and  near  the  insertion  of  the  recti  muscles.  It  has  a 
smooth  surface,  and  is  of  a  dusky  red  color,  and  is  appa- 
rently caused  b}'  some  plastic  effusion  on  the  sclerotic. 
There  is  geuerallj'  some  redness  of  the  conjunctiva  imme- 
diately over  it,  and  sometimes  chemosis.  The  dark  hue 
of  the  swelling  seems  due  to  its  being  supplied  by  the 
deep  subconjunctival  vessels,  which  in  some  cases  ma}'  be 
seen  running  up  to  it.  The  affection  appears  to  be  local 
and  confined  to  one  side  of  the  cornea.  The  degree  of 
suffering  it  produces  is  very  variable.  In  some  patients 
I  have  seen  considerable  irritation,  with  severe  neuralgic 
pain  in  the  eye-,  whilst  in  others  the  onl}'  annoyance  has 
been  the  disfigurement  which  the  bloodshot  appearance 
has  produced.  The  disease  is  generally  very  tedious  in 
its  course,  and  frequently  recurrent.  For  a  time  the 
swelling  seems  to  increase  in  size  and  redness  ;  it  then 
gradually  fades  in  color,  diminishes,  and  ultimatel}'  dis- 
appears. 

Treatment. — When  there  is  no  irritation,  a  mild  stimu- 
lating application  to  the  eye  does  the  most  good,  and  the 
guttse  zinci  chlorid.  (F.  19),  or  the  guttte  zinci  sulphatis 
(F.  20),  may  be  ordered  twice  a  daj'.  If,  however,  there 
is  photophobia  and  lachrymation,  the  guttae  atropite  (F. 
13),  or  the  lotio  belladonna,  should  be  prescribed.     The 


INJURIES    OF    THE    CORNEA    AND    SCLEROTIC,  85 

state  of  health  should  be  carefully  inquired  into,  and  if 
any  irregularity  of  the  functions  of  any  of  the  organs  be 
detected,  suitable  medicines  should  be  prescribed.  In 
some  cases  I  have  found  benefit  from  the  administration 
of  the  iodide  of  potassium,  given  either  with  an  alkali 
(F.  74)  or  with  small  doses  of  iron  (F.  73),  according  to 
the  requirements  of  the  patient. 

injuries  of  the  cornea  and  sclerotic. 

Foreign  Bodies  on  the  Cornea  or  on  the  Conjunc- 
tiva  Lining  the  Lids. 

Symptoms. — Great  irritability  of  the  e3'e,  accompanied 
b}'  a  copious  flow  of  tears,  an  almost  absolute  inability 
to  raise  the  upper  e3'elid  and  face  the  light,  and  a  dis- 
tinct feeling  of  grittiness  as  if  something  were  in  the  eye. 
The  suddenness  of  the  attack,  and  the  exposure  to  which 
the  eye  has  been  subjected,  are  also  points  to  be  noted. 

Treatment. — The  cornea  should  be  first  well  scanned 
over,  turning  the  head  of  the  patient  in  various  directions 
so  as  to  cause  the  light  to  fall  obliquely  on  the  eye  first 
on  one  part  of  its  surface  and  then  upon  another ;  or  by 
using  a  two-inch  focus  lens  a  column  of  light  may  be 
directed  over  the  cornea,  so  as  to  illumine  each  portion  of 
it  in  succession.  Failing  to  find  a  foreign  body  on  the 
cornea,  the  inner  surfaces  of  the  eyelids  should  be 
next  examined ;  and  this  is  to  be  done  by  drawing 
down  the  lower  lid  and  everting  the  upper  one. 

If  the  foreign  body  is  not  deeply  buried^  but 
merel}'  lying  on  the  surface,  or  sunk  into  the  epi- 
thelium of  the  cornea  or  conjunctiva  of  the  lids, 
it  may  be  easily  removed  b}^  a  spud  (Fig.  2)  or  by 
a  broad  needle.  iji^ 

If  the  foreign  body  is  buried  deep)ly  in  the  cor-  i  i 
neal  tissue,  a  broad  needle  should  be  passed  into,  iJLJ! 
but  without  penetrating,  the  cornea.     Inserting  it  just  by 


86         INJUllIES    OF   THE    CORNEA   AND    SCLEROTIC. 

the  side  of  the  object,  it  should  be  made  to  traverse  the 
corneal  lamellae  until  the  broad  part  of  the  blade  is  behind 
the  foreign  body,  when,  b}'  thus  giving  a  firm  su})port  upon 
which  to  act,  another  needle  may  be  fearlessly  used  to 
pick  gently  from  the  surface  until  it  reaches  the  object, 
which  can  then  be  lifted  away.  Should,  however,  the  for- 
eign body,  have  so  deeply  penetrated  the  cornea  that  it 
is  feared  any  attempts  to  reach  it  from  its  surface  ma}'^ 
end  in  pushing  it  into  the  anterior  chamber,  a  broad 
needle  should  be  passed  into  the  anterior  chamber,  and 
pressed  against  the  inner  surface  of  the  cornea  immedi- 
ately behind  the  foreign  body,  and  carefully  and  steadily 
held  in  this  position,  whilst  the  surgeon,  with  another 
needle,  scrapes  through  the  cornea,  layer  after  layer,  until 
he  reaches  it. 

Having  removed  the  foreign  body,  one  or  two  drops  of 
olive  or  castor  oil  may  be  dropped  into  the  eye.  The 
eyes  should  not  be  used  for  two  or  three  days,  and  if  there 
is  pain,  or  a  continuance  of  the  irritation  excited  by  the 
foreign  body,  two  or  three  leeches  should  be  applied  to 
the  temple,  and  the  eye  fomented  with  hot  water  or  de- 
coction of  poppy-heads  or  belladonna  (F.  8,  9). 

Abrasions  of  the  Cornea. — An  abrasion  of  the  cor- 
nea is  the  forcible  removal  of  a  portion  of  the  epithelium 
from  its  surface.     It  is  always  the  result  of  an  injury. 

Symj^foms. — Immediately  after  the  accident  there  is 
photophobia,  great  lachrymation,  and  conjunctival  red- 
ness, with  a  feeling  as  if  a  foreign  body  were  in  the  eye. 
On  examination  of  the  eye  before  a  good  light,  the  abra- 
sion will  be  recognized  by  the  glistening  facet,  which  will 
be  seen  at  the  part  where  the  cornea  has  been  denuded 
of  its  epithelium. 

Proynosii< — Favorable  in  a  healthy  person  ;  but  in  a 
delicate  or  exhausted  patient,  ulceration  of  the  cornea, 


ABRASIONS    OF   THE    CORNEA.  87 

diffuse  suppurative  corneitis,  and  ultimate  loss  of  the  eye, 
may  be  caused  by  this  apparently  slight  accident.  Abra- 
sions of  the  cornea  frequently  occur  in  mothers  who  are 
suckling ;  the  child  unconsciously  claws  at  the  eye,  and 
scratches  off  a  little  of  the  epithelium  from  the  cornea. 
As  the  health  of  the  mother  during  lactation  is  often  very 
unfavorable  for  the  repair  of  injuries,  veiy  troublesome 
results  may  follow. 

Treatment. — If  there  is  a  simple  abrasion  of  the  cornea, 
and  the  patient  is  seen  soon  after  the  accident,  a  drop  of 
castor  or  olive  oil,  or  cream  dropped  into  the  eye,  will 
often  give  temporary  relief,  and  may  be  repeated  every 
two  or  three  hours  for  the  first  day  or  two.  Gently  clos- 
ing the  eye  and  applying  over  it  a  cotton-wool  compress 
with  a  single  turn  of  a  soft  roller  will  give  great  ease,  by 
effectually  excluding  the  e^^e  from  light,  and  by  prevent- 
ing the  up  and  down  movement  of  the  lid,  which  serves 
to  irritate  the  abraded  surface.  If  the  ej'e  is  very  pain- 
ful, the  bandage  may  be  removed  three  or  four  times 
during  the  day,  whilst  the  eye  is  bathed  with  hot  water, 
or  with  a  decoction  of  poppy-heads,  and  two  leeches  may 
be  applied  to  the  temple.  If  untoward  symptoms  come 
on,  such  as  ulceration  or  abscess  of  the  cornea,  warmth 
and  soothing  remedies  are  still  best  suited.  A  warm 
belladonna  fomentation  (F.  8)  may  be  used,  frequently 
appljdng  it  to  the  eye  with  a  hollow  sponge  so  as  to  steam 
it,  and  thus  relax  and  soothe  the  inflamed  parts.  In  ad- 
dition to  this,  two  or  three  drops  of  a  solution  of  atropine, 
gr.  1  ad  aquse  ^  1,  may  be  dropped  twice  a  day  into  the 
eye.  If  the  aqueous  grows  turbid,  and  hypopion  follows, 
tapping  the  anterior  chamber  with  a  fine  needle,  and  let- 
ting off  the  aqueous,  will  often  do  good. 

When  abrasions  of  the  cornea  take  on  these  unfavora- 
ble symptoms,  as  they  frequently  do,  it  is  usuall}^  on  ac- 
count of  some  condition  of  the  patient's  health  si)ecially 


00  INJURIES    OF    THE    CORNEA    AND    SCLEROTIC. 

unfavorable  for  the  repair  of  injuries.  Too  great  plethora, 
anaemia,  a  constitution  broken  b}'  drink  and  rough  living, 
or  one  enfeebled  from  some  exhausting  cause,  such  as 
suckling,  ma}^  retard  recovery-  or  induce  symptoms  dan- 
gerous to  the  eye.  Such  conditions  of  sj'stem  must  regu- 
late our  constitutional  treatment.  In  the  one  class  of 
cases  moderate  antiphlogistic  treatment  will  be  called  for, 
Tvhilst  in  the  other  the  patient  must  be  propped  up  by 
stimulants,  and  all  irritation  be  alla^'ed  bj^  sedatives. 
Opiates  in  these  cases  are  of  the  greatest  service,  and  a 
few  minims  of  the  liq.  opii  sedativ.  combined  with  llq. 
cinchonjB  given  three  or  four  times  a  day  will  sometimes 
completelj"  change  the  character  of  the  inflammation,  and 
induce  a  healthy  action  and  a  speedy  recovery.  If  it 
should  be  preferred  to  give  the  opiate  in  one  dose  at 
night,  it  should  be  sufficient  in  quantity  to  produce  sleep, 
as  a  single  moderate  dose  will  excite  rather  than  tran- 
quillize. 

Penetrating  Wounds  of  the  Cornea  and  Sclerotic, 
— A  small  incised  wound  of  either  the  cornea  or  sclerotic, 
provided  none  of  the  other  textures  of  the  eye  are  injured, 
is  almost  harmless  ;  it  rapidly  heals,  and  no  after  incon- 
A'cnience  is  experienced.  We  have  evidence  of  this  in 
the  numerous  operations  on  the  eye^  and  especially  in 
those  for  cataract  and  iridectomy.  Wounds,  however, 
which  are  produced  by  accident,  are  generally  compli- 
cated by  either  contusion,  hemorrhage,  prolapse,  wound 
of  the  lens,  or  loss  of  vitreous ;  and  sometimes  b}'  all 
these  casualties  together.  The  danger  of  a  corneal  wound 
is  immensely  increased  if  it  should  extend  into  the  ciliary 
region,  as  there  is  then  great  risk  of  the  other  eye  be- 
coming aftected  with  sympathetic  ophthalmia. 
I  Wounds  in  the  sclerotic  are  far  more  fatal  to  the  eye 
I  than  similar  wounds  in  the  cornea;  they  are  also  some- 


PENETRATING    WOUNDS.  89 

times  difficult  to  heal,  and  especially  if  the  cut  is  at  a 
distance  from  the  margin  of  the  cornea,  and  there  has 
been  loss  of  vitreous.  They  will  generally  remain  patu- 
lous, and  show  no  attempt  at  closing.  This  apparent 
incapacity  to  unite,  is  solely  due  to  the  peculiarly  un- 
jdelding  nature  of  the  sclerotic,  which  prevents  the  lips 
of  the  wound  from  falling  accurately  together,  when  the 
contents  of  the  globe  have  been  suddenly  diminished  by 
a  loss  of  vitreous.  If,  however,  3'ou  can  succeed  in  bring- 
ing the  edges  correctly  in  contact,  union  will  at  once  take 
place.  This  fact  has  been  proved  on  several  occasions, 
by  the  rapid  healing  of  such  patulous  wounds  of  the 
sclerotic  after  the}'  have  been  closed  by  a  single  fine  silk 
suture. 

Treatment. — The  primary  treatment  must  be  soothing ; 
the  patient  should  be  kept  in  a  subdued  light,  and  the 
injured  eye  should  be  closed,  and  a  compress  bandage 
(F.  2)  applied  over  the  lids.  Two  or  three  leeches  should 
be  applied  to  the  temple,  thus  anticipating  rather  than 
waiting  for  any  excessive  action  which  may  arise,  and 
one  or  two  drops  of  a  solution  of  atropine  (F.  13)  should 
be  dropped  into  the  eye  twice  a  day,  each  time  the  com- 
press is  readjusted.  After  a  few  days  the  compressing 
bandage  may  be  discontinued,  and  warm  or  cold  applica- 
tions to  the  eye  may  be  substituted  in  accordance  with 
the  feelings  of  the  patient.  Belladonna  may  be  used 
either  in  the  form  of  a  cold  lotion  or  a  warm  fomentation. 

The  Constitutional  treatment  will  vary  somewhat  with 
the  condition  of  the  patient.  It  must,  however,  be  re- 
membered that  affections  of  the  cornea,  even  though  they 
are  traumatic,  will  not  bear  much  depletion.  The  in- 
flammation which  follows  such  injuries  is  reparative  in 
its  action,  and  requires  to  be  watched  and  kept  from  ex- 
ceeding its  proper  limits,  rather  than  that  means  should 
be  taken  completely  to  check  it,  as  the  part  may  iierisli 


90         INJURIES    OF    THE    CUllNEA    AND    SCLEROTIC. 

from  a  waut  of  A'ital  action,  as  well  as  from  an  excess  of 
energy. 

If  the  patient  is  robust,  a  brisk  purgative  (F.  87,  88) 
may  be  prescribed,  with  some  saline  or  diaphoretic  medi- 
cine (F.  .55,  52).  A  regular  antiphlogistic  course  is  sel- 
dom if  ever  required.  A  moderate,  well-regulated  diet, 
the  avoidance  of  more  stimulants  than  the  case  demands, 
and  rest  both  to  the  eyes  and  body,  place  the  patient  in 
the  condition  most  favorable  for  recovery.  Pain  in  the 
e^'e  suflicient  to  prevent  sleep  should  be  relieved  by 
opiates,  taking  care  at  the  same  time  that  there  is  a  regu- 
lar daily  action  of  the  bowels. 

In  delicate  and  feeble  patients  it  may  be  necessarj'  to 
order  from  the  very  commencement  a  liberal  diet  and  a 
certain  amount  of  stimulants ;  and  to  prescribe  tonics, 
such  as  the  mineral  acids  with  cinchona,  or  quinine  (F. 
61,  64),  combining  a  few  minims  of  liq.  opii  with  each 
dose,  to  allay  the  constant  irritability  which  injuries  to 
the  cornea  often  excite  in  such  patients;  or  the  opiate 
maj'  be  given  in  one  full  dose  at  bedtime. 

For  wounds  of  the  cornea  complicated  with  prolapse 
of  the  iris,  or  wounds  of  the  lens,  see  articles  Prolapse 
OP  THE  Iris,  and  Traumatic  Cataract. 

Rupture  or  the  Eye  through  the  Sclerotic — 
This  is  the  most  severe  injury  that  can  happen  to  the 
eye.  It  either  destroys  the  eye  at  once,  or  else  so  impairs 
it  that  it  seldom  sufficiently  recovers  to  be  of  much  ser- 
vice. It  is  usually  caused  bj*  blows  on  the  eye  with  the 
fist,  or  with  some  blunt  or  semi-blunt  instrument,  or  by 
the  patient  falling  and  striking  his  eye  against  some  pro- 
jecting object.  The  exact  part  at  which  the  eye  will  burst 
depends  partly  on  the  situation  of  the  point  which  re- 
ceives the  force  of  the  blow ;  still  the  locality  in  which 
the  rupture  takes  place  is  so  frequently  the  same  that 


RUPTURE    OF    THE    EYE.  91 

the  coincidence  must  be  due  to  more  th<au  mere  accidental 
circumstances. 

The  split  in  the  sclerotic  is  almost  invariably  near  the 
margin  of  the  cornea,  following  somewhat  the  direction 
of  its  curvature,  about  one-sixteenth  to  one-eighth  of  an 
inch  distant  from  it,  and  immediatel}'  anterior  to  the 
insertion  of  the  recti  muscles.  The  rent  most  commonly 
occurs  in  the  horizontal  diameter  and  upper  region  of  the 
eye,  in  a  line  extending  inwards  from  between  the  margin 
of  the  cornea  and  the  superior  rectus.  The  next  most 
frequent  site  is  towards  the  inner  side  between  the  cornea 
and  the  internal  rectus.  It  is  comparatively  seldom  that 
it  occurs  to  the  lower  or  outer  side  of  the  cornea.  If  the 
rent  is  either  to  the  inner  or  the  outer  side  of  the  cornea, 
the  split  is  more  or  less  vertical,  thus  following  the  curve 
of  the  cornea. 

The  cornea  itself  may  be,  and  is  frequently,  ruptured 
by  blows  on  the  eye  ;  but  the  injury  when  confined  to  the 
cornea  is  usually  less  severe  and  the  result  less  disastrous 
than  when  the  rent  is  through  the  sclerotic.  A  blow  to 
rupture  the  sclerotic  must  be  direct  or  nearly  so,  and  in- 
flicted with  great  force ;  whereas  a  side  or  glancing  one 
will  split  the  cornea. 

In  rupture  of  the  sclerotic,  the  injurj^  is  unfortunately 
not  confined  to  the  laceration  only  of  this  coat.  The 
force  which  is  required  to  produce  it  is  so  great  that  all 
the  tissues  within  the  eye  suffer  more  or  less.  A  por- 
tion of  the  iris  is  often  prolapsed  through  the  w^ound,  and 
in  some  cases  the  greater  part  or  even  the  whole  of  the 
iris  is  detached  and  shot  out  with  the  lens.  The  lens  is 
usually  dislocated ; — most  frequently  it  is  jerked  out 
through  the  wound,  and  escapes  unnoticed. 

There  is  generally  free  hemorrhage  from  the  different 
structures  of  the  eye  involved  in  the  injury.  From  the 
torn  iris  and  ciliary  processes  blood  is  usually  effused 


92  INJURIES    OF    THE    CORNEA    AND    SCLEROTIC. 

into  the  anterior  chamber  and  into  the  vitreous ;  and  from 
the  ruptured  choroidal  vessels  blood-clots  are  formed  be- 
tween the  choroid  and  retina,  and  frequently  also  between 
the  choroid  and  sclerotic.  Vitreous  humor  may  escape 
from  the  wound  at  the  time  of  the  accident,  and  occasion- 
ally in  a  suthcient  quantity  to  cause  a  partial  collapse  of 
the  globe. 

Prognosis. — Our  prognosis  in  cases  of  rupture  of  the 
eye  must  alwa3's  be  very  unfavorable ;  the  wound  is  a  con- 
tused and  lacerated  one — the  most  unfavorable  for  pri- 
mary union — and  it  is  in  the  ciliary  region,  the  part  of 
the  eye  worst  suited  for  the  reception  of  injuries. 

There  are,  however,  cases  in  which  a  certain  amount 
of  sight  is  regained  after  a  rupture  of  the  globe  through 
the  sclerotic,  and  in  my  work  on  "Injuries  of  the  Eye"  I 
have  recorded  the  history  of  patients,  who  after  a  rupture 
of  the  globe  and  dislocation  of  the  lens  from  the  eye  have 
recovered  sufficient  sight  to  be  able  to  read  with  a  lens 
No.  20  of  Jaeger's  test  types.* 

Treatment. — When  the  patient  is  seen  shorth' after  the 
accident  which  has  ruptured  tlie  sclerotic,  it  is  often  diffi- 
cult to  ascertain  the  exact  amount  of  damage  the  eye  has 
sustained,  as  the  anterior  chamber  is  usually  filled  with 
blood,  and  the  deeper  parts  of  the  636  thus  masked  from 
observation.  In  such  cases  it  is  well  to  watch  the  patient 
and  to  wait  a  few  da^ys  before  deciding  on  the  ultimate 
course  to  be  adopted.  Two  or  three  leeches  should  be 
applied  to  the  temple  of  the  injured  side,  and  repeated  in 
twelve  or  twenty-four  hours  if  the  eye  is  very  painful. 
Soothing  applications  atlbrd  the  greatest  relief,  and  a 
double  fold  of  linen  wet  with  the  opium  or  the  belladonna 
lotion  (F.  35,  32),  maj'  be  laid  over  the  closed  lids.  If 
the  eye  progresses  favorably,  towards  the  end  of  the  week 

*  Injuries  of  the  Eye,  Orbit,  and  Eyelids,  p.  2G6. 


IRITIS.  93 

the  blood  in  the  anterior  chamber  will  have  been  suffici- 
ently absorbed  to  allow  of  a  more  accurate  examination 
being  made.  The  patient,  though  unable  to  discern  ob- 
jects, ought  now  to  have  a  fair  perception  of  light:  failing 
to  possess  this,  a  very  unfavorable  prognosis  must  be 
formed. 

If,  after  a  fair  trial  of  treatment,  the  eye  is  found  to 
be  irreparably  destroyed  for  all  purposes  of  vision,  my 
own  feeling  is,  that  it  is  by  far  the  safest  and  wisest  plan 
to  remove  it ;  a  long  period  of  certain  anxiety  will  be 
thus  saved;  all  further  suffering  will  be  ended,  and  the 
safety  of  the  other  e3e  will  be  secured. 

There  are,  however,  certain  cases  of  rupture  of  the 
globe,  in  which  the  injury  has  been  so  extensive,  that 
the  eye  has  been  manifestly  destro^-ed  at  the  time  of  the 
accident.  A  severe  rent  in  the  sclerotic  or  cornea,  with 
extrusion  of  the  lens,  and  a  portion  of  the  iris  and  cho- 
roid, together,  perhaps,  with  a  collapsed  or  softened  state 
of  the  globe  from  a  loss  of  vitreous,  would  render  any 
attempt  to  preserve  the  eye  not  only  futile  but  trifling. 
After  such  an  injurj^,  the  onl}'  proper  treatment  is  at  once 
to  excise  the  globe. 


CHAPTER  III. 

DISEASES   OF    THE    IRIS    AND    VITREOUS    HUMOR. 

Iritis,  or  Inflammation  of  the  Iris,  may  be  a  pi^i- 
marij  disease,  or  it  may  be  secondary  to  an  inflammation 
of  one  or  other  of  the  coats  of  the  eye. 

Frimary  Iritis  may  arise :  1.  From  some  constitutional 
taint,  as  syphilis  or  rheumatism.  2.  From  sudden  expos- 
ure to  cold.     3.  From  an  injury  to  the  eye,  which  may  be 


94  DISEASES    OF   THE    IRIS. 

either  mechanical  or  chemical,  and  to  this  form  the  term 
traumatic  is  applied. 

Secondary  Iritis  is  caused  by  the  extension  of  an  in- 
flammation from  one  of  the  tissues  of  the  eye  with  which 
the  iris  is  connected,  as  in  corneo-iritis  and  choroido-iritis  ; 
the  first  word  in  each  name  indicating  the  site  in  which 
the  disease  commenced.  Primary  iritis  may  also,  in  its 
turn,  implicate  secondarily  the  neighboring  structures; 
thus  we  have  irido-cyclitis  and  irido-choroiditis.  In  the 
first-mentioned  case  the  ciliary  body  has  become  secon- 
darily involved ;  and,  in  the  second,  the  choroid.  Some 
authors  have  classified  iritis  in  accordance  with  the  in- 
flammatory exudation,  which  is  supposed  to  characterize 
each  form  of  the  disease,  and  have  described  iritis  as 
plastic,  serous,  and  suppurative.  It  should,  however,  be 
remembered  that  iritis  is  seldom  either  solel}'  plastic,  se- 
rous, or  suppurative ;  in  rheumatic  and  syphilitic  iritis 
we  have  eft'usions  both  of  serum  aiid  h'mph  ;  and  trau- 
matic iritis  is  often  at  first  serous  and  afterwards  sup- 
purative. I  prefer,  therefore,  where  it  is  practicable,  to 
prefix  to  the  term  iritis  the  name  of  its  exciting  cause,  as 
it  indicates  the  course  of  treatment  to  be  adopted.  I 
shall  describe,  therefore,  in  sections,  the  following  varie- 
ties of  the  disease,  and  shall  point  out  the  peculiarity  of 
the  inflammatory  exudations  in  each. 

1.  Syphilitic, 

2.  Rheumatic, 

3.  Serous,  V    Iritis. 

4.  Suppui'ative, 

5.  Traumatic, 

Iritis  may  be  either  acute  or  chronic,  but,  whichever  it 
is,  its  symptoms  and  progress  are  modified  by  the  cause 
which  produced  it. 


IRITIS.  95 

XtEneral  Symptoms  of  Iritis. — The  aqueous  becomes 
yellow  and  serous,  and,  as  the  disease  advances,  it  fre- 
quently grows  turbid  from  flocculi  of  Ij'mph  or  pus,  which 
will  sometimes  sink  to  the  bottom  of  the  anterior  cham- 
ber, forming  hypopion. 

The  iris  loses  its  striated  appearance  from  lymph  ef- 
fused on  its  surface  and  into  its  texture ;  its  color  be- 
comes consequently  changed,  and  its  brilliancy  is  dulled. 
A  blue  or  a  gray  iris  assumes  a  greenish  hue,  and  the 
darker  irides  grow  of  a  rusty  or  brownish  red.  The 
change  of  color  of  the  iris,  at  the  commencement  of  the 
attack,  is  often  more  apparent  than  real,  and  is  due  to  the 
iris  being  seen  through  a  yellow  serous  aqueous,  which 
imparts  to  a  blue  or  a  gray  iris  a  greenish  tinge,  but,  in 
the  more  advanced  stages  the  altered  color  and  loss  of 
striation  is  dependent  on  fibrinous  effusion. 

The  pupil  is  contracted  and  sluggish  in  its  action,  and 
the  pupillary  margin  soon  contracts  adhesions  to  the 
capsule  of  the  lens,  at  first  only  at  points,  so  that  when 
dilated  with  atropine,  the  unattached  parts  only  being 
acted  on,  the  pupil  assumes  a  jagged,  irregular  outline. 
But  if  the  disease  be  unarrested  by  treatment,  the  whole 
pupillary  margin  becomes  sealed  to  the  lens  capsule, 
forming  what  is  tenned  complete  synechia  ;  and  so  firm 
is  the  bond  of  adhesion,  that  atropine  will  frequently  fixil 
to  dilate  any  portion  of  the  pupil.  The  disease  still  pro- 
gressing, lymph  is  effused  on  the  capsule  of  the  lens 
within  the  pupillary  space. 

The  Vascularity  of  the  Eye  in  Iritis. — The  conjunctival 
surface  is  generally  suffused,  and,  in  some  cases,  there  is 
great  redness  with  slight  oedema ;  but  the  chief  seat  of 
the  increased  vascularity  is  in  the  ciliary  vessels,  which 
are  seen  as  a  red  zone  around  the  cornea.  This  vascular 
ring  is  one  of  the  early  symptoms  of  iritis,  and  one  of  the 
most  constant. 


96  DISEASES    OF   THE    IRIS. 

In  severe  cases  tlie  increased  vascularitj'  of  the  iris  is 
so  great,  tliat  distended  varicose  vessels  may  be  often 
seen  witli  the  unaided  eye  coursing  along  the  surface  of 
the  iris. 

The  impairment  of  vision  is  alwaj^s  considerable,  and 
it  increases  as  the  disease  advances.  It  is  due  to  the  fol- 
lowing causes  :  the  turbid  aqueous,  the  lymph  on  the  cap- 
sule of  the  lens  in  the  pupillary  area,  and  frequently,  also, 
to  the  impaired  power  of  accommodation  caused  by  an 
extension  of  the  inflammation  to  the  ciliary  body. 

The  degree  of  pain  in  iritis  is  very  variable ;  in  some 
cases  it  is  slight,  whilst  in' others  it  is  most  acute,  and 
forms  one  of  the  prominent  symptoms.  The  pain  is  of  a 
neuralgic  character — in  the  eye,  around  the  brow,  extend- 
ing upwards  over  the  side  of  the  head,  and  downwards 
along  one  side  of  the  nose.  In  syphilitic  iritis  the  pain 
is  usually  slight,  whilst  in  the  rheumatic  form  it  is  often 
very  intense. 

Intolerayice  of  light  is  not,  as  a  rule,  a  marked  symp- 
tom in  iritis.  There  is  generally  some  photophobia,  but 
it  is  seldom  that  it  amounts  to  the  intense  dread  of  light 
which  is  witnessed  in  some  of  the  affections  of  the  cor- 
nea. To  this,  however,  there  are  occasional  exceptions; 
and,  in  a  few  cases  of  rheumatic  and  traumatic  iritis,  I 
have  seen  as  much  photophobia  as  is  met  with  in  the 
most  acute  corneitis. 

In  iritis  there  is  a  strong  tendency  to  recurrence.  An 
eye  which  has  once  suffered,  is  rendered  specially  liable 
to  another  attack,  and  this  is  peculiarly  the  case  in  the 
rheumatic  form  of  the  disease.  So  frequent,  indeed,  are 
the  recurrences  of  this  variety  of  iritis,  that,  hy  some,  it 
is  designated  by  the  special  name  of  recurrent  iritis. 
Such  are  the  general  symptoms  of  iritis,  but  any  one  of 
them  may  be  modified  by  the  cause  which  has  given  rise 
to  the  disease.     I  will  now  briefly  consider  some  of  the 


IRITIS.  97 

characteristic  and  diagnostic  sjmiptoms  of  the  special 
forms  of  iritis  ah'eady  mentioned  at  page  94, 

Syphilitic  Iritis  usually  first  appears  during  the  sec- 
ondary eruption,  or  just  as  it  is  beginning  to  fade.  It 
is  characterized  by  a  peculiar  tendency  to  the  rapid  effu- 
sion of  lymph,  which,  if  not  arrested  by  appropriate  treat- 
ment, soon  leads  to  permanent  damage  to  the  eye.  The 
effusion  of  13'mph  is  often  so  copious,  that  nodules  of  it 
as  large  as  millet -seeds  will  be  seen  along  the  margin  of 
the  iris,  and  sometimes  the  deposits  are  in  single  isolated 
patches  of  a  greater  size.  1  have  seen  a  third  of  the  iris 
covered  with  one  solid  mass  of  lymph,  and  the  pupil  com- 
pletely occluded  by  it.  I  have  never  known  a  case  of 
syphilitic  iritis  go  on  to  suppuration.  The  pain  and 
dread  of  light  are  not  usually  marked  symptoms,  and 
certainly  are  not  so  severe  as  is  commonly  found  in  the 
rheumatic  form  of  the  disease. 

Treatment  of  Syphilitic  Iritis. — Mercury  is  here  im- 
perativel}^  called  for.  It  should  be  given  in  doses  sufli- 
cienfl^^  large  and  frequent  to  bring  the  patient  quickly 
under  its  influence,  but,  as  soon  as  the  gums  begin  to 
grow  tender  and  spong}^,  the  quantity  should  be  dimin- 
ished so  as  to  avoid  anj'thing  like  profuse  salivation.  A 
piece  the  size  of  a  nut  of  the  unguent,  hydrarg.  may  be 
rubbed  into  the  axilla  night  and  morning ;  or  a  pill,  with 
calomel  and  opium  (F.  94),  may  be  given  three  times  a 
day.  If  the  patient  is  feeble,  quinine  may  be  prescribed 
at  the  same  time,  and  this  may  be  convenientlj'^  ordered 
in  a  pill  or  mixture  (F.  64)  during  the  day,  whilst  the 
mercurial  inunction  is  used  night  and  morning.  If  the 
patient  has  already  been  salivated  before  he  first  comes 
under  treatment,  the  iodide  of  potassium  mixture  (F.  H) 
should  be  given,  and  a  slight  mercurial  action  may  be 
kept  up  by  a  little  of  the  unguent,  hydrarg.  c.  belladonna 

9 


98  DISEASES    OF   THE    IRIS. 

(F,  99)  being  rubbed  into  the  brow  and  temple,  and 
allowed  to  remain  on  during  the  day;  or,  if  the  patient 
can  bear  it,  pil.  hydrarg.  siibchlorid.  comp.  gr.  5  may  be 
ordered  every  other  night.  When  all  the  effused  lymph 
has  been  absorbed,  and  the  iritis  has  nearly  subsided, 
the  mercurial  medicines  should  be  omitted,  but  the  iodide 
of  potassium  should  be  continued  for  two  or  three  months 
combined  with  a  bitter  tonic,  or,  if  the  patient  is  ansemic, 
with  some  preparation  of  iron  (F.  73).  If  the  iritis  recur 
after  some  months,  or  if  it  assume  a  chronic  form,  a  mix- 
ture of  the  perchloride  of  mercury  with  the  iodide  of 
potassium  (F.  78)  will  be  often  found  of  great  service. 
Atropine  is  essential  in  the  treatment  of  every  form  of 
iritis,  and  should  be  ordered  at  the  ver}^  commencement 
of  the  attack,  and  persevered  in  during  its  continuance. 
A  solution  of  the  strength  of  gr.  2  ad  aquae  ^  1  should  be 
dropped  into  the  eye  twice  or  three  times  a  da3\  The 
object  is  to  keep  the  pupil  dilated,  and,  by  so  doing,  to 
tear  through  any  adhesions  which  may  have  formed  be- 
tween it  and  the  lens  capsule.  It  also  allays  irritation, 
and,  by  paralyzing  the  accommodative  power,  places  the 
eye  in  a  state  of  rest.  When  the  atropine  fails  to  give 
ease,  or  acts  as  it  does  in  exceptional  cases  as  an  irri- 
tant, the  belladonna  lotion  (F.  32)  may  be  substituted. 

Rheumatic  Iritis  is  chiefly  a  serous  inflammation ; 
some  lymph  is  efi'used,  suflEicient  to  cause  tags  of  adhesion 
between  the  iris  and  lens  capsule,  or  even  in  severe  cases 
to  produce  a  complete  closure  of  the  pupil ;  but  it  is  not 
poured  out  as  in  the  syphilitic  form  in  quantities  to  be 
easily  seen  on  the  surface  of  the  iris  with  the  naked  e3'e. 
The  aqueous  is  yellow  and  serous.  The  apparent  change 
of  color  in  the  iris  in  rheumatic  iritis  is  often  mainly  due 
to  the  yellow  aqueous  through  which  it  is  seen.  I  have 
frequentty  noticed  the  greenish  colored  iris  at  once  re- 


IRITIS.  99 

stored  to  its  normal  gra}''  or  blue,  when  the  yellow  aque- 
ous escaped,  either  from  a  puncture  in  paracentesis  of 
the  cornea,  or  ii%the  operation  of  iridectomy.  Rheu- 
matic iritis  is  often  associated  with  rheumatism  else- 
where, such  as  pains  in  the  limbs  or  joints ;  or  the  pa- 
tient has  suffered  previously  from  rheumatic  fever.  In 
some  cases  where  there  are  frequent  recurrences  of  iritis, 
the  patient  is  never  completely'  free  from  rheumatic  pains ; 
if  the  limbs  and  the  joints  are  exempt,  the  soles  of  the 
feet  or  the  heels  are  tender. 

Rheumatic  iritis  is  very  recurrent,  and  although  the 
e3"e  may  recover  from  each  attack,  yet  fresh  traces  of  the 
disease  are  each  time  left,  which  greatlj^  cripple  if  they  do 
not  eventually  destroy  the  eye.  Gonorrhoea!  rheumatism 
is  often  followed  by  a  serous  iritis  of  a  very  recurrent  na- 
ture, and  in  no  way  differing  from  the  ordinary  rheumatic 
type  of  the  disease. 

In  one  patient  who  was  under  my  care,  the  recurrence 
of  the  iritis  was  usually  preceded  by  a  return  of  the  ure- 
thral discharge,  which  lasted  for  a  few  days  and  then  dis- 
appeared. The  pain  in  rheumatic  iritis  is  severe  and 
neuralgic,  and  sometimes  ver}'  intense.  There  is  also 
frequently  a  gTeat  dread  of  light,  which  is  often  quite  out 
of  proportion  to  the  severity  of  the  attack.  I  haA'e  had 
patients  with  rheumatic  iritis  suffer  from  such  intense 
photophobia,  that  they  were  unable  to  tolerate  a  ray  of 
light  in  their  room,  and  for  a  time  lived  in  absolute  dark- 
ness. This  excessive  dread  of  light  is  however  excep- 
tional. 

Treatment. — Rheumatic  iritis  does  not  require  the  ac- 
tive mercurial  treatment  recommended  for  the  syphilitic 
form  of  the  disease.  Iodide  of  potassium  in  small  doses 
combined  with  the  bicarbonate  of  potash  (F.  Y4)  may  be 
given  during  the  day,  and  at  night  a  pill  with  calomel  gr. 
1,  pulv.  ipecac,  comp.  gr.  5  ;  or  the  unguent,  hydrarg.  c. 


100  DISEASES    OF   THE    IRIS. 

belladonna  (F.  99)  ma}'  be  rubbed  dail}-  into  the  temple. 
In  some  cases  this  treatment  will  fail  to  give  anj^  relief, 
and  quinine  in  2-grain  doses  may  the^  be  ordered  with 
great  benefit;  or  the  quinine  may  be  combined  with  the 
tinct.  ferri  perchlorid.  (F.  66).  When  there  is  great  pho- 
tophobia and  pain  in  the  eye,  the  quinine,  or  quinine  and 
iron  treatment,  together  with  a  mild  mercurial  inunction 
into  the  temple  will  be  found  most  i;seful ;  to  relieve  the 
pain  a  fourth  or  a  third  of  a  grain  of  the  acetate  of  mor- 
phia (F.  24)  may  be  injected  subcutaneously  into  the  arm. 
Turpentine  has  been  prescribed  with  advantage  in  obsti- 
nate cases  of  non-syphiUilc  iritis.  The  ol.  terebinth,  may 
be  ordered  in  small  and  repeated  doses  as  in  (F.  81)  ;  or 
the  Chian  turpentine  may  be  given  in  5-grain  doses  three 
times  a  day.  During  the  whole  of  the  attack  of  iritis  the 
pupil  should  be  kept  dilated  either  by  means  of  atropine, 
or  with  the  belladonna  lotion  (F.  32). 

Serous  Iritis. — Aquo-capsulitis — Keratitis  punctata — 
comes  on  frequently  without  anj-  apparent  cause,  and  is 
most  commonly  seen  in  young  peojile,  and  in  those  who 
•present  either  the  markings  of  the  teeth  or  the  creasings 
about  the  mouth  which  point  to  some  hereditary  taint  of 
s^'philis.  It  is  characterized  by  an  increased  secretion  of 
the  aqueous,  which  is  usually  somewhat  turbid,  and  by 
small  punctated  opacities  on  the  posterior  surface  of  tlie 
cornea.  These  opacities  are  caused  by  a  deposition  of 
small  conical  masses  of  lymph  from  the  aqueous  humor. 

Symptoms. — Diffused  haziness  of  the  cornea  with  small 
dotted  opacities  on  its  posterior  surface.  The  anterior 
chamber  is  deepened  from  an  increased  secretion  of 
aqueous,  which  is  serous  and  slightly  turbid.  The  iris  is 
a  little  discolored  from  being  viewed  through  a  3-ellovvish 
medium,  and  the  pupil  is  either  of  about  its  normal  size 
or  slightly  dilated.     In  this  respect  serous  iritis  shows  a 


IRITIS.  101 

marked  difference  from  all  the  other  forms  of  inflamma- 
tion of  the  iris,  and  it  is  to  be  attributed  to  the  increased 
tension  which  is  so  often  met  with  in  this  affection,  and 
also  to  its  being  freqnentl3'  associated  with  disease  of  the 
deeper  structures  of  the  eye.  There  is  increased  vascu- 
larit3'^,  especially  in  the  ciliary  region.  Occasionally  there 
is  much  pain,  dread  of  light,  and  lachrymation,  but  these 
are  by  no  means  constant  symptoms,  as  in  some  patients 
they  are  excessive,  whilst  in  others  one  or  all  may  be  al- 
most wanting. 

Treatment  of  Serous  Iritis. — Small  doses  of  the  iodide 
of  potassium  combined  with  iron  (F.  73),  or  with  a  bitter 
tonic  (F.  74),  ma}' be  prescribed;  or  if  the  patient  is  very 
feeble,  quinine  with  iron  (F.  65),  or  the  mineral  acids 
with  bark  (F.  61)  will  be  better  suited.  In  children  the 
syrup  of  the  iodide  or  phosphite  of  iron  (F.  114,  117), 
will  be  often  found  beneficial,  with  small  alterative  doses 
of  the  hj'drarg.  cum  creta  cum  rheo  (F.  122,  123),  once 
or  twice  a  week.  The  pupil  should  be  kept  under  the  in- 
fluence of  atropine,  and  the  ej'es  frequently  bathed  with 
the  belladonna  lotion.  The  internal  administration  of 
mercury,  except  in  occasional  alterative  doses,  is  prejudi- 
cial. If  the  eye  should  become  glaucomatous,  an  iridec- 
tomy should  be  performed. 

Suppurative  Iritis  is  generally  consequent  on  an  in- 
jury, or  it  may  follow  an  operation  on  the  eye,  but  it  may 
also  occur  without  any  very  apparent  cause  in  patients 
who  are  in  a  low  state  of  health.  The  disease  is  charac- 
terized by  a  rapid  inflammatory  exudation  which  soon 
fills  the  pupil.  The  iris  at  first  appears  haz}^,  and  the 
markings  of  it  indistinct  or  lost;  its  surface  then  becomes 
partially  or  entirely  coated  with  a  film  of  puro-lj^mph. 
Particles  of  lymph  and  pus  gravitate  to  the  bottom  of  the 
anterior  chamber,  and  constitute  the  condition  known  as 

9* 


102  DISEASES    OF    THE    IRIS. 

h^'popion.  Up  to  this  stage  the  cornea  will  often  con- 
tinue clear  and  bright,  and  if  the  iritis  is  now  arrested, 
the  eye  may  recover,  but  the  i)upil  will  be  closed  by  ad- 
hesions to  the  capsule  of  the  lens,  and  by  a  false  mem- 
brane. Unfortunatel}'  the  disease  usually  progresses,  the 
cornea  next  grows  steam}'  and  dull,  it  then  ulcerates  in 
part,  pus  is  effused  between  its  lamina?,  and  onyx  is 
formed  ;  perforation  will  follow,  and  the  eye  will  be  prob- 
ably, for  all  useful  purposes,  lost.  (For  treatment,  see 
Traumatic  Iritis,  next  section.) 

Traumatic  Iritis  is  due  to  an  injurj^,  generally  a  pene- 
trating wound,  of  the  eye,  which  has  iuA'olved  either  the 
iris,  or  the  lens,  or  both.  It  is  most  apt  to  follow  when  the 
iris  is  either  contused  or  lacerated,  or  partially  strangled, 
as  in  cases  of  prolapse. 

Wounds  of  the  lens  are  peculiarl}'  apt  to  cause  iritis : 
the  lens  swelling  from  the  imbibition  of  the  aqueous 
presses  on  the  back  or  uveal  surface  of  the  iris,  and  acts 
as  a  most  powerful  irritant.  We  have  illusti'ations  of 
this  occasional!}'  after  needle  operations  for  soft  cataract, 
or  after  the  extraction  of  hard  cataracts,  when  fragments 
of  cortical  matter  remain  after  the  lens  has  been  taken 
away. 

Traumatic  iritis  may  occur  in  two  forms — the  acute 
and  chronic. 

TJie  acute  usually  comes  on  within  the  first  four  or  five 
days  after  the  injury,  and  is  ushered  in  with  oedema  of 
the  lids  and  chemosis  of  the  conjunctiva.  The  inflamma- 
tion may  be  p/as^ic,  producing  a  rapid  exudation  of  lymph 
into  the  pupil  and  on  to  the  surface  of  the  u-is,  but  moi-e 
frequenthat  is  suppurative  (see  preceding  section,  p.  101). 
Acute  traumatic  iritis  may  terminate  in  three  wa3's:  1. 
Under  suitable  treatment  the  eye  may  recover ;  but  as 
the  result  of  the  inflammation,  there  w  ill  probably  remain 


IKITIS.  103 

a  more  or  less  complete  closure  of  the  pupil  from  a  false 
membraue,  with  adhesions  of  the  pupillary  border  of  the 
iris  to  the  lens  capsule.  2.  The  acute  symptoms  may 
gradually  subside,  and  then  become  chronic.  3.  It  may 
destroy  the  eye  by  an  extension  of  the  inflammation  to 
the  cornea,  or  to  the  deeper  structures — the  choroid  and 
retina. 

The  chronic  form  usually  commences  from  one  to  three 
weeks  after  an  injury.  It  is  frequentl}'  seen  after  opera- 
tions for  the  extraction  of  cataract,  and  especially  if  the 
iris  has  been  much  pressed  upon  in  the  passage  of  the 
lens  from  the  eye.  It  is  always  accompanied  with  pho- 
tophobia and  lachrymation,  and  the  edges  of  the  lids 
often  become  puffy,  thickened,  and  excoriated.  The 
aqueous  becomes  serous  and  the  striation  of  the  iris  in- 
distinct. The  pupil  is  but  slightly  and  irregularly  acted 
on  by  atropine,  and  there  is  a  slow  dull  pain  in  the  eye. 
This  chronic  condition  will  last  frequently  many  weeks, 
and  it  yields  but  slowly  to  treatment. 

Treatment. — In  this  form  of  the  disease  mercur}-  is 
seldom  required,  and  in  the  early  stages  of  it  shouhl  not 
be  prescribed.  The  iritis  is  due  to  an  injurj^,  and  time 
and  rest  must  be  given  to  allow  the  eye  to  recover  from 
the  mischief  it  has  sustained.  Soothing  applications  to 
the  eye  are  beneficial.  The  solution  of  atropine  (F.  13) 
should  be  dropped  into  the  eye  two  or  three  times  daily, 
and  a  fold  of  linen  wet  with  the  belladonna  lotion  (F.  32) 
ma}"  be  laid  over  the  closed  lids.  If  there  is  much  pain, 
two  or  three  leeches  should  be  applied  to  the  temple,  and 
these  may  be  repeated  if  necessary.  The  bowels  should 
be  freely  acted  on  by  a  mild  purgative  ;  and  if  there  is 
much  constitutional  irritation,  an  effervescing  or  saline 
mixture  (F.  53,  55)  may  be  given  during  the  day,  and  an 
opiate  at  night  to  relieve  pain.  After  the  first  acute  symjD- 
toms  have  passed  away,  the  patient  will  generally  be  bene- 


104  DISEASES    OF    THE    IRIS. 

fited  by  the  mineral  acids  with  bark  (F.  61).  If  the  iritis 
should  become  chronic,  a  slight  mercurial  inunction  into 
the  temple  will  often  afford  relief.  If  the  iritis  is  .swp- 
purative^  and  there  is  hypopion,  warm  ai)plications  will 
afford  the  greatest  comfort,  and  the  fotus  belladonnae 
(F.  8)  or  fotus  papaveris  (F.  9)  may  be  ordered.  When 
there  is  hypopion  and  great  pain,  paracentesis  of  the  cor- 
nea will  often  be  found  ver}'  beneficial. 

Cysts  of  the  Iris  usually  occur  after  an  injury-  to  the 
eye,  generally  a  penetrating  wound,  from  which  the  iris 
has  suffered  either  by  prolapse  or  puncture ;  but  they  are 
occasionalh^  met  with  in  eyes  where  no  assignable  cause 
for  their  origin  can  be  traced.  Thej^  are  round  or  oval 
in  shape,  and  generally  filled  with  a  transparent  fluid. 
Although  apparentl}"  on  the  surface  of  the  iris,  yet  they 
are  developed  in  its  substance  between  the  anterior  or 
muscular,  and  the  posterior  or  uveal  laj'cr  of  the  iris. 
Mr.  Bowman,  in  his  Lectures  on  the  eye,*  says,  "  It  is 
evident  in  this  disease,  that  the  muscular  tissue  of  the 
iris  is  expanded  over  the  fluid  ;"  and  further  on,  "  that  the 
uvea  (which  is  always  dark)  is  not  j^rotruded  with  the 
muscular  tissue,  but  separated  and  thrown  posteriorly; 
for  if  it  were  in  front  of  the  fluid  of  the  vesicle,  its  pig- 
ment would  be  obvious  enough  in  the  attenuated  tissue, 
whereas  it  is  not  visible  there." 

In  a  case  which  came  under  the  care  of  Mr.  Hulke,  the 
cyst  was  pedunculated,  and  he  succeeded  in  removing  it 
entire.  In  the  microscopical  examination  which  he  after- 
wards made,  he  was  enabled  to  confirm  the  description 
previously  recorded  by  Mr.  Bowman.  He  found  that  "  the 
cyst-wall,  was  a  delicate,  homogeneous  membrane,  varying 

*  Lectures  on  the  Parts  concerned  in  the  Operations  on  the  Ej'e, 
1849,  p.  76. 


CYSTICERCUS    ON    THE    IRIS.  105 

from  4  a'oo''  to  hbVo"  ""^  thickness.  Its  outer  siirface  was 
overlaid  by  a  net  of  fusiform  cells,  identical  with  those  of 
the  contractile  tissue  of  the  iris;  and  its  inner  surface  was 
lined  b}'  a  pavement  epithelium,  the  cells  of  which  differed 
much  in  size  in  different  parts  of  the  cyst."*  A  cyst  of 
the  iris  may  exist  without  giving  the  patient  any  incon- 
venience, but  if  it  increases  so  as  to  encroach  upon  the 
pupil,  it  at  once  produces  impairment  of  vision.  It  may, 
however,  excite  great  irritation,  and  in  the  case  already 
mentioned  as  having  been  reported  b}^  Mr.  Hulke,  it  gave 
rise  to  sympathetic  symptoms  in  the  other  eye. 

Treatment. — Excise  the  cj'st  with  the  portion  of  iris  to 
which  it  is  attached.  This  is  best  accomplished  bj^  the 
ordinary  operation  of  iridectomy,  taking  care  that  the 
cyst  is  drawn  out  of  the  wound  before  the  segment  of  iris 
is  cut  off  with  the  scissors.  Puncturing  the  cyst  with  a 
fine  needle  has  been  tried,  but  with  only  temporary  suc- 
cess, as  the  cavity  soon  refilled. 

Cysticercus  on  the  Iris — Cj^sticerci  may  appear  on 
the  iris,  in  the  vitreous,  or  behind  the  retina.  They  look 
like  transparent  vesicles,  with  a  slight  constriction  in  one 
part,  dividing  the  head  from  the  body.  When  on  the  iris, 
the  hydatid  cyst  should  be  removed,  and  this  may  be 
readily  accomplished  by  excising  the  portion  of  iris  on 
which  the  vesicle  is  implanted,  as  in  the  operation  of  iri- 
dectomy. An  interesting  example  of  this  rare  disease  is 
recorded  by  Mr.  T.  Pridgin  Teale  in  the  Royal  London 
Ophthalmic  Hospital  Reports,  vol.  v,  page  320.  A  cysti- 
cercus within  the  eye  must  be  regarded  as  a  very  grave 
afiection ;  and  if  it  be  detected  in  the  vitreous,  an  attempt 
should  be  made  to  remove  it,  even  though  the  endeavor 

*  Royal  London  Of)hthiilmic  Hospital  Reports,  vol.  vi,  p.  12. 


106  DERANGEMENTS   OF   THE    IRIS. 

to  do  SO  would  necessitate  a  preliminary  extraction  of  the 
lens,  as  in  the  case  recorded  by  Von  Graefe.* 

Melanotic  Sarcoma,  or  Carcinoma,  will  occasionally 
spring  from  the  iris,  although  the  usual  site  for  these 
growths  is  from  the  choroid.  When  the  disease  has  been 
satisfactorily  diagnosed,  there  should  be  no  delay  in  ex- 
cising the  eye.     See  Tumors  of  the  Choroid. 

FUNCTIONAL    DERANGEMENTS    OF    THE    IRIS. 

Mydriasis,  or  dilatation  of  the  pupil,  may  arise  from 
intra-  and  extra-ocular  causes,  and  also  from  the  action  of 
certain  drugs  on  the  sphincter  pupillos  of  the  iris. 

The  intra-ocular  changes,  or  morbid  states  of  the  eye, 
which  produce  mydriasis,  are — increased  or  glaucomatous 
tension  of  the  globe ;  diseases  of  the  choroid  or  retina ; 
and  injuries  which  affect  the  ciliary  nerves  either  by 
laceration  or  by  pressure  on  them  from  a  bloodclot. 

The  extra-ocular  causes  are  complete  paraWsis  of  the 
third  nerve,  or  palsj^  only  of  those  filaments  of  it  which 
supply  the  pupil ;  disease  of  the  optic  nerve  beyond  the 
e3''e ;  or  the  presence  of  a  cerebral  tumor  or  some  other 
disease  of  the  brain.  It  is  often  ver}'  difficult  to  ascer- 
tain the  cause  of  mydriasis,  as  it  will  frequently  occur 
suddenly  in  one  eye,  without  any  other  paralj'tic  symp- 
toms, and  with  only  a  very  slight  impairment  of  vision. 
In  this  condition  I  have  known  an  eye  remain  for  many 
years,  the  pupil  continuing  fixedly  dilated  a  third  or  a 
half  more  than  that  of  the  other  eye,  and  without  any 
farther  evidence  of  disease  being  manifested.  In  such 
cases  it  is  probable  that  there  is  no  absolute  paralysis  of 
the  filaments  of  the  third  nerve  which  supply  the  iris, 

*  Archiv  fiir  Ojihtluilmologie,  iv,  2,  171. 


MYDRIASIS.  107 

but  simply  a  preponderance  of  power  in  the  radiating 
over  the  sphincter  fibres,  possibly  due  to  some  reflex  irri- 
tation. This  theory  is  strengthened  by  the  fact  that 
atropine  will  usually  induce  a  further  dilatation,  show- 
ing that  the  sphincter  of  the  iris  still  exerted  some  con- 
trol in  limiting  the  size  of  the  pupil.  With  mydriasis 
there  is  a  diminution  and  sometimes  complete  loss  of  the 
accommodative  power  of  the  eye.  To  ascertain  if  the 
impairment  of  vision  is  due  solely  to  the  dilated  pupil,  it 
is  only  necessary  to  try  the  effect  of  making  the  patient 
look  with  the  aflTected  eye  through  a  pin-hole  aperture  in 
a  piece  of  card  held  close  to  the  eye,  when  if  the  retina 
is  sound,  the  acuteness  of  vision  will  be  restored. 

Of  the  drugs  which  exercise  a  dilating  influence  on  the 
pupil,  the  most  prominent  are  belladonna,  stramonium, 
hyoscyamus,  and  conium.  The  sulphate  of  atropia  pre- 
pared from  belladonna  is  the  most  rapid  and  efficient  of 
all  mydriatics  we  at  present  possess.  Its  effects  are  pro- 
duced b}^  the  solution  of  atropia  permeating  the  cornea, 
and  coming  into  direct  contact  with  the  nerves  of  the  iris. 
This  has  been  proved  by  tapping  the  anterior  chamber 
of  an  eye  under  the  influence  of  atropine,  and  with  the 
aqueous  dilating  the  pupil  of  another  eye.  Its  action  is 
chiefly  if  not  entirely  due  to  its  paralyzing  the  filaments 
of  the  third  n«rve,  which  go  to  the  iris,  and  thus  pro- 
ducing complete  relaxation  of  the  sphincter  pupillaa. 

From  Ruete's  observations  it  would  appear  that  atro- 
pine stimulates  the  radiating  or  dilating  fibres  of  the  iris 
to  contract,  as  he  found  that  the  widely  dilated  pupil 
which  accompanies  complete  paralysis  of  the  third  nerve 
would  expand  further  under  the  influence  of  atropine. 
In  practice  the  sulphate  of  atropia  is  preferred  to  the 
alkaloid,  on  account  of  its  greater  solubility.  Applied  to 
the  eye  in  solution,  it  is  in  most  cases  a  direct  sedative, 
but  after  long-continued  and  frequent  instillation,  it  will 


108  DERANGEMENTS    OF   THE    IRIS. 

often  create  a  good  deal  of  conjunctival  irritation.  In 
exceptional  cases  it  is  a  powerful  irritant,  and  will  give 
rise  to  acute  inflammatory'  symptoms.  I  have  related 
examples  of  these  anomalous  effects  of  atropine  in  a  short 
paper  in  the  Ophthalmic  Hospital  Reports.*  They  are 
no  doubt  due  to  some  peculiar  idiosyncrasy  on  the  part 
of  the  patient  which  renders  him  intolerant  of  atroijine. 
It  has  been  suggested  that  the  presence  of  some  free  acid 
is  the  reason  of  the  sulphate  of  atropia  acting  occasion- 
ally as  an  irritant ;  but  this  theory  is  untenable,  as  the 
drug  is  a  neutral  salt. 

Myosis,  or  contraction  of  the  pupil,  may  arise  from  a 
spasmodic  action  of  the  sphincter  pupillse,  or  from  a  loss 
of  power  in  the  dilator  or  radiating  fibres  of  the  iris.  It 
may  be  produced  by  hyperoesthesia  or  over-sensibility  of 
the  retina;  or  it  maybe  acquired  from  the  constant  habit 
of  working  at  minute  objects,  as  in  watchmaking,  &c. 
The  most  frequent  cause,  however,  of  myosis,  is  some 
affection  of  the  spino-sj-mpathetic  filaments  which  supply 
the  radiating  or  dilating  fibres  of  the  iris.  M^'osis  is  met 
with  in  disease  of  the  upper  part  of  the  spinal  cord — that 
portion  of  it  which  sends  nervous  filaments  to  the  cer- 
vical S3'mpathetic  ganglia.  Tumors  in  the  neck  pressing 
on  the  sympathetic  nerves  have  been  long  known  to  pro- 
duce myosis.  Dr.  Oglef  has  reported  a  ver}-  interesting 
case  in  which  the  right  carotid  was  tied  bj'  Mr.  Henry 
Lee,  on  account  of  an  aneurism  in  the  right  side  of  the 
neck.  The  right  pupil  was  small  (not  contracted,  how- 
ever, so  much  as  it  might  be),  and  not  influenced  bj'  the 
light  of  a  candle,  whilst  the  left  pupil  was  large  and  re- 

*  On  some  of  the  Anomalous  Effects  of  Atropine  on   the  Eye. 
Koyal  London  Ophthiilmic  Hospital  Reports,  vol.  vi,  p.  119. 
t  Lancet,  March  13,  18G9. 


MYOSIS.  109 

sponsive  to  light.  The  man  had  been  for  nineteen  years 
and  a  half  a  soldier,  and  had  generally  enjoyed  good 
health  until  about  five  years  before,  when  he  was  shot  by 
a  bullet,  which  passed  through  the  outer  third  of  the  right 
clavicle,  making  its  exit  about  an  inch  behind  that  bone. 
Between  seven  and  eight  weeks  afterwards,  the  wound 
quite  healed,  and  he  rejoined  his  regiment  in  the  field. 
Since  that  time  he  has  had  a  series  of  abscesses  in  the 
neck.  He  was  ultimately  invalided  to  England,  and  sent 
to  Netley,  where  he  was  found  to  have  an  aneurism  in 
the  neck,  for  which  he  was  afterwards  admitted  into  St. 
George's  Hospital.  In  this  patient,  the  mj'osis  was  prob- 
sibly  due  to  injury  of  the  cervical  sympathetic  nerve. 

Atropine  has  usuall}'  but  little  influence  upon  the  con- 
tracted pupil ;  it  ma}'  enlarge  it  slightl}',  but  it  will  sel- 
dom dilate  it  widely,  showing  that  the  cause  of  the  m^-osis 
in  such  cases  is  due  to  a  more  or  less  complete  paral3'sis  of 
the  radiating  fibres  of  the  iris,  which  will  not  dilate  the 
pupil  even  when  the  sphincter  or  circular  fibres  have  been 
completely  relaxed.  The  pupils  of  one  or  both  eyes  may 
be  affected  with  m3'Osis.  I  have  seen  several  cases  where 
both  pupils  have  been  contracted  to  the  size  of  pin's  heads, 
and  have  remained  in  this  state  for  j'ears  without  more 
annoyance  than  a  slight  diminution  in  the  acuteness  of 
vision.  When  myosis  is  dependent  on  some  morbid  state 
of  the  spino-sympathetic  nerves,  there  is  generally  a  great 
desire  for  strong  lights,  with  which  the  patient  is  often 
able  to  read  the  smallest  type ;  but  in  a  subdued  light  the 
sight  is  often  very  defective.  I  have  lately  had  a  patient 
suffering  from  extreme  m3'Osis  who  literally  surrounds 
himself  at  night  with  a  blaze  of  artificial  lights  to  enable 
him  to  read,  whilst  b^^  day  he  sits  with  the  full  glare  of 
the  sun  on  his  book. 

Another  defect  which  is  occasionally'  met  with  in  spinal 
mj'osis,  is  color-blindness.     Dr.  Arg3dl  Robertson  has  re- 

10 


110  DERANGEMENTS    OF   THE   IRIS. 

\  centl}'^  related  in  a  pamphlet,*  a  A'ery  interesting  case  of 
1  spinal  disease  in  which  myosis  and  color-blindness  were 
j  prominent  s^'mptoms.  lie  has  also  cited  other  instances 
I  of  this  peculiar  impairment  of  sight  as  having  been  pro- 
j  duced  both  by  disease  and  injury  of  the  spinal  cord. 

Calabar  Bean — Phr/sostigmatis  Faba. — Contraction 
of  the  pupil  may  be  artificiall}'  produced  b}'^  applying  a 
solution  of  the  Calabar  bean  to  the  eye  (F.  15),  or,  what 
is  more  convenient,  one  or  two  of  the  small  gelatine  discs 
impregnated  with  this  drug.  For  the  knowledge  we  pos- 
sess of  the  peculiar  properties  of  the  Calabar  bean  we  are 
indebted  to  Dr.  Fraser  and  Dr.  Argyll  Robertson.  The 
former  gentleman  in  1862  discovered  its  influence  on  the 
pupil;  and  the  latter  in  1863,  its  effects  upon  the  accom- 
modation of  the  eye. 

The  Calabar  bean  rapidlj^  induces  extreme  contraction 
of  the  pupil,  and  a  myopic  state  of  vision,  and  this  it  does 
by  stimulating  the  branches  of  the  third  nerve,  and  pro- 
ducing a  temporary  spasm  of  the  sphincter  pupilla^  and 
ciliary  muscle.  In  from  five  to  ten  minutes  after  the  ap- 
plication of  the  drug  the  pupil  begins  to  contract,  and  in 
from  half  to  three-quarters  of  an  hour  it  has  reached  its 
maximum  effect.  The  pupil  is  then  reduced  to  rather 
less  than  a  line  in  diameter,  and  the  eye  is  rendered 
myopic,  the  near  and  far  points  being  approximated  to 
the  eye.  These  changes  last  for  a  variable  time  in  ac- 
cordance with  the  strength  of  the  solution  which  has  been 
used.  The  accommodative  power  is  often  restored  in  a 
few  hours,  whilst  it  will  frequently  take  two  or  three  days 
before  the  pupil  will  regain  its  normal  size.  The  bean 
also  possesses  the  power  of  counteracting  for  a  time  the 
influence  of  atropine.     Thus,  if  a  little  of  a  strong  solu- 

*  Eye  Symptoms  in  Spinal  Disease.  Oliver  &  Boyd,  Edinburgh, 
1869. 


OPERATIONS. 


Ill 


tion  is  introduced  into  the  eye  whilst  the  pupil  is  dilated 
to  its  utmost  with  atropine,  it  will  gradually  cause  it  to 
contract  to  its  natural  size,  and  sometimes  even  below  it, 
if  the  dilatation  of  the  pupil  is  due  to  a  weak  solution  of 
atropine.  This  efl'ect,  however,  of  the  bean  is  evanescent, 
and  passes  off  in  a  few  hours  as  the  atropine  resumes  its 
sway  over  the  pupil. 

Treatment  of  3Iydriasis  and  Myosin No  special  line 

of  treatment  can  be  laid  down  for  the  cure  of  these  func- 
tional derangements  of  the  iris  ;  they  are  dependent  on  so 
many  and  such  varied  conditions.  An  endeavor  should 
be  made  to  ascertain  the  cause  of  the  altered  state  of  the 
pupil,  and  according  to  the  information  thus  gained  the 
patient  must  be  treated.  In  mydriasis  a  weak  solution 
of  atropine,  and  in  myosis  one  of  Calabar  bean  ma}'  be 
used  once  daily  to  the  eye,  if  they  afford  relief.  In  such 
cases  the  gelatine  discs  of  atroi)ine  and  Calabar  bean  are 
very  useful. 

OPERATIONS    ON    THE    IRIS. 

The  Operation  of  Iridectomy. — A  spring-stop  specu- 
lum having  been  placed  between  the 
lids,  the  operator,  standing  behind  tlie 
head  of  the  patient,  seizes  with  a  pair 
of  forceps  in  his  left  hand  the  conjunc- 
tiva and  subjacent  fascia  of  the  eye^  at 
a  part  near  the  cornea,  opposite  to  that 
at  which  he  is  about  to  introduce  the 
point  of  the  iridectomy  knife;  whilst 
with  his  right  hand  he  makes  an  inci- 
sion in  the  sclerotic  with  a  lance-shaped 
knife  (Fig.  3)  at  about  one  line  from  the 
margin  of  the  cornea,  so  that  the  point 
of  it  may  enter  the  anterior  chamber 
just  in  front  of  the  ciliary  attachment 
of  the  iris.     In  directina:  the  blade  of 


Fra.  3. 


112 


OPERATIONS    ON    THE    IRIS. 


the  knife  across  the  anterior  chamber,  care  should  l)e 
taken  to  keep  the  point  of  the  insti'ument  slightly  for- 
wards, so  as  to  avoid  the  risk  of  wounding  the  lens.  The 
surgeon  now  hands  over  the  forceps,  which  fixed  the  eye^ 
to  his  assistant,  who,  if  necessary,  rotates  the  globe  a 
little  downwards,  and  steadies  it  whilst  he  excises  a  por- 
tion of  the  iris.  If  the  iris  is  already  prolapsed,  as  often 
happens,  he  at  once  seizes  it  with  a  pair  of  iris  forceps 
(Fig.  4),  or  if  not,  he  introduces  the  ])lades  of  the  forceps 
through  the  wound,  and  makes  them  grasp  the  iris  near 
the  pupillary  border,  and  then  drawing  a  portion  of  it  out 
of  the  wound,  he  cuts  it  otf  with  a  pair  of  fine  scissors. 

Fig.  4. 


When  the  anterior  chamber  is  so  shallow  that  the  iridec- 
tomy knife  cannot  be  used  without  incurring  the  risk  of 
wounding  the  lens,  the  incision  in  the  sclerotic  should  be 
made  with  an  ordinary  cataract  knife,  or  with  Graefe's 
linear  extraction  knife.  The  point  of  the  blade,  after  it 
has  pierced  the  sclerotic,  should  be  directed  along  the 
rim  of  the  anterior  chamber  for  a  distance  in  accordance 
with  the  desired  size  of  the  incision,  and  then  making 
the  counter-puncture,  it  should  cut  its  wa^'  out  as  in  the 
ordinary  flap  extraction. 


Artificial  Pupil. — To  gain  the  full  benefit  which  an 
artificial  pupil  will  atford  in  properly  selected  cases,  the 
cornea  should  be  first  very  carefull}'  examined,  and,  if 
necessary,  by  oblicpie  illumination  with  ophthalmoscoi»ic 
light,  to  determine  the  part  opposite  to  which  an  artificial 


ARTIFICIAL    PUPIL.  113 

pupil  will  be  the  most  effective.  In  examining  the  cornea, 
the  two  points  to  be  noted  are,  first,  its  transparency,  and 
next,  its  curvature :  that  part  should  be  selected  which  is 
the  most  transparent,  and  which  has  the  most  normal 
curve. 

The  operation  most  in  use  for  the  formation  of  an  arti- 
ficial pupil  is  iridectomy ;  but  there  are  many  cases  for 
which  it  is  not  suited,  when  one  of  the  following  methods 
may  be  selected,  according  to  the  special  indications 
which  the  eye  may  present : 

1.  With  a  broad  needle  and  Tyrrell's  hook. 

2.  By  iridodesis  or  ligature  of  the  iris. 

3.  By  incision  of  the  iris. 

4.  By  excision  of  a  triangular-shaped  piece  of  the  iris. 

1.  To  make  an  Artificial  Pupil  with  a  broad  Needle 
and  TyrrelVs  Hook. — The  patient  lying  on  a  couch,  a 
spring-stop  speculum  (Fig.  5)  is  to  be  introduced  between 

Fto.  5. 


the  lids,  so  as  to  keep  them  apart.  The  operator,  stand- 
ing behind  the  head  of  the  patient,  with  one  hand  seizes 
the  conjunctiva  and  submucous  tissue  of  the  eye  with  a 
pair  of  forceps,  so  as  to  steady  it,  whilst  with  the  other 
he  makes  an  opening  in  the  extreme  margin  of  the  cornea 

10* 


114  OPERATIONS    ON    THE    IRIS. 

Avitli  a  broad  needle.  Having  completed  the  incision,  the 
broad  needle  is  to  be  withdrawn,  and  the  eye  be- 
FiG^  6.  ji^g  g^iii  l^Q\^\  ]^y  ii^Q  forceps,  a  Tyrrell's  hook  ( Fig. 
6)  is  to  be  passed  t^idcways  through  the  corneal 
wound  into  the  anterior  chamber,  and  onwards 
across  the  iris  to  the  pupil,  when  it  is  to  be  turned 
with  the  hook  downwards,  so  as  to  catch  the  \m- 
pillary  edge  of  the  iris,  and  then  to  be  slowh'  and 
carefully  withdrawn  from  the  eye.  When  the  hook 
approaches  the  opening  at  the  margin  of  the  cor- 
nea, it  must  be  again  turned  on  its  side,  or  a  dif- 
ficulty will  be  experienced  in  getting  it  out  of  the 
eye.  As  soon  as  the  iris  is  drawn  from  the  eye^  the  as- 
sistant should  cut  it  off  close  to  the  cornea  with  one  snip 
of  a  pair  of  fine  scissors.  The  operation  is  now  finished ; 
the  speculum  should  be  removed  from  the  eye,  and  a  fold 
of  wet  linen  laid  over  the  closed  lids. 

This  operation  is  applicable  to  those  cases  where  there 
is  a  pupil,  or  at  least  a  portion  of  one,  to  the  free  edge  of 
which  the  hook  can  fasten  itself. 

2.  Artificial  Pupil  by  Iridodesis,  or  Ligature  of  the 
Iris. — This  operation  was  first  suggested  and  practised 
b}^  Mr.  Critchett,  who  published  an  account  of  in  the 
Royal  London  Ophthalmic  Hospital  Keports,  vol.  i,  page 
220.  It  may  be  performed  as  follows  :  The  patient  l.ying 
on  his  back,  a  spring-stop  speculum  is  placed  between 
the  lids,  and  the  operator  with  one  hand  lays  hold  of  the 
conjunctiva  of  the  ej'e  with  a  pair  of  forceps,  to  fix  it, 
whilst  with  the  other  he  makes  an  opening  with  a  broad 
needle  through  the  extreme  margin  of  the  cornea.  A  suf- 
ficiently large  incision  having  been  made  for  the  intro- 
duction of  the  hook,  or  the  forceps,  or  whatever  instru- 
ment is  to  be  used  to  seize  the  iris,  the  broad  needle  is 
withdi'awn,  and  a  small  loop  of  fine  silk  is  then  laid  over 
the  wound.   H'the  hook  (Fig.  fi)  is  the  instrument  selected, 


ARTIFICIAL    PUPIL.  115 

it  is  introduced  by  the  corneal  wound  into  the  anterior 
chamber,  passing  through  the  loop  of  silk ;  and  catching 
the  pupillary  edge  of  the  iris,  it  is  slowly  and  carefully 
drawn  out  of  the  e3'e,  dragging  with  it  the  piece  of  iris  it 
holds  into  the  loop  of  silk.  As  soon  as  the  iris  is  within 
the  loop,  the  assistant,  with  a  pair  of  cilia  forceps  in  each 
hand,  seizes  hold  of  its  two  ends  and  draws  them  firmly 
together,  so  as  to  cause  the  strangulation  of  the  protruded 
portion  of  iris,  and  at  the  same  time  to  prevent  its  slip- 
ping back  through  the  incision  into  the  anterior  chamber. 
The  two  ends  of  the  ligature  may  now  be  cut  off,  but  one 
end  should  be  left  longer  than  the  other,  for  the  conveni- 
ence of  catching  hold  of  it  with  a  pair  of  forceps  if,  with 
the  resecretion  of  the  aqueous,  it  should  be  drawn  within 
the  corneal  wound. 

It  is  a  matter  of  importance  not  to  make  the  incision 
in  the  margin  of  the  cornea  too  large,  as  although  at  the 
time  it  facilitates  the  operation,  yet,  as  the  aqueous  is  re- 
stored, the  piece  of  iris,  with  the  ligature  on  it,  may  be 
sucked  back  into  the  anterior  chamber. 

3.  Artificial  Pupil  by  Incision  of  the  Iris. — This  oper- 
ation is  only  suited  to  a  special  class  of  cases  :  those  eyes 
in  which  there  is  no  lens^  and  in  which  no  trace  of  a  pupil 
remains,  the  iris  appearing  as  a  plane  surface  stretched 
tightly  from  the  cicatrix  to  the  circumference  of  the 
cornea. 

A  broad  needle  is  to  be  passed  through  the  cornea  into 
the  anterior  chamber,  and  along  the  plane  of  the  iris,  to 
the  point  where  it  is  desired  to  make  the  new  pupil ;  it  is 
then  to  be  turned  with  its  edge  and  point  towards  the 
iris,  when,  by  suddenly  depressing  the  hand,  the  needle 
is  made  to  penetrate  the  iris  and  to  cut  a  small  slit  across 
its  fibres.  The  needle  is  then  to  be  withdrawn,  and  if 
the  iris  is  healthy  the  edges  of  the  incision  will  at  once 
retract,  and  a  good  pupil  will  be  formed.     If,  however, 


116  OPERATIONS    ON    THE    IRIS. 

owing  to  the  iris  having  lost  its  natural  elasticity,  the 
edges  of  the  cut  should  fail  to  retract  so  as  to  form  a  new 
pupil,  a  Terrell's  hook  should  l)e  introduced  through  the 
opening  in  the  cornea  already  made  with  the  broad  needle, 
and  having  caught  one  edge  of  the  incision  in  the  iris, 
it  should  be  gentl}^  drawn  out  of  the  eye,  and  the  piece  of 
iris  it  brings  with  it  cut  off  with  a  pair  of  fine  scissors. 

4.  Artificial  Pupil  by  Excision  of  a  triangulaT-shaped 
piece  of  the  Iris. — This  operation  has  been  practised  by 
Mr.  Bowman  in  cases  where  the  pupil  has  become  closed 
and  drawn  towards  the  cicatrix  in  the  cornea  after  ex- 
traction of  the  lens,  and  also  where  there  has  been  closed 
pupil  with  extensive  posterior  synechijB  after  sympathetic 
ophthalmia  or  irido-choroiditis.  The  operation  is  per- 
formed as  follows :  The  lids  being  separated  with  a  spring 
speculum,  an  incision  is  commenced  in  the  corneo-sclei'o- 
tic  junction  with  one  of  Graefe's  cataract  knives,  as  if  for 
the  extraction  of  cataract,  but  the  blade  is  withdrawn 
from  the  eye  before  the  section  is  completed,  and  thus 
two  lateral  openings  are  made,  with  a  bridge  of  cornea 
between  them.  Through  one  of  these  a  pair  of  scissors, 
the  anterior  blade  of  which  is  probe-pointed,  is  intro- 
duced, and  a  triangular-shaped  piece  of  iris  is  excised. 
To  accomplish  this  the  posterior  blade  is  made  to  per- 
forate the  iris  and  the  subjacent  parts  to  which  it  is  ad- 
herent, and  with  one  snip  downwards  a  cut  is  made  to  a 
point  just  below  the  normal  position  of  the  pupil ;  a  simi- 
lar cut  is  then  made  on  the  other  side  of  the  iris  to  the 
same  point,  and  the  two  lines  of  incision  are  joined  at 
their  base  by  a  third  cut  with  the  scissors.  A  triangular 
portion  of  iris  is  thus  included  between  the  three  in- 
cisions, and  this  is  then  lifted  awa}'  with  a  pair  of  iris 
forceps. 

If  the  lens  is  still  in  the  eye  it  is  at  once  extracted.  By 
this  operation,  not  only  is  a  large  pupil  made,  but  from 


HEMORRHAGE.  117 

the  circular  fibres  of  the  iris  having  been  removed,  the 
tendenc}^  for  it  again  to  close  is  greatly  diminished, 

INJURIES    TO    THE    IRIS. 

Hemorrhage  into  the  Anterior  Chamber. — This 
is  the  most  common  form  of  intraocular  hemorrhage,  and 
at  the  same  time  the  least  severe.  It  may  A^ary  in  extent 
from  a  few  drops  of  blood  to  a  quantity  sufficient  to  fill 
both  the  anterior  and  the  posterior  chambers. 

The  most  usual  causes  of  hemorrhage  into  the  anterior 
chamber  are,  either  ruptui'e  of  one  or  more  of  the  super- 
ficial vessels  of  the  iris,  or  a  distinct  laceration  of  its 
structure ;  or  a  detachment  of  a  portion  of  the  iris  from 
its  ciliarjr  circumference  (coredialysis).  The  blood,  as  it 
is  effused  from  the  lacerated  A^essels  of  the  iris,  sinks  at 
once  to  the  bottom  of  the  anterior  chamber,  quickly 
coagulates,  and,  if  not  much  in  quantity,  may  be  seen  as 
a  small  clot  occupying  its  lower  part,  and  moulded  as  it 
were  to  it.  If,  however,  the  bleeding  be  more  severe,  the 
whole  anterior  chamber  may  be  filled  with  one  large 
coagulum,  which  will  entirely  occlude  the  pupil  and  iris. 
This  more  extensive  hemorrhage  is  usually  owing  to  a 
detachment  of  the  iris  from  its  ciliary  border,  when,  on 
account  of  the  number  of  vessels  necessarily  torn  through, 
and  also  of  their  larger  size,  the  quantity  of  blood  which 
is  poured  out  is  considerable. 

Prognosis  and  Treatment — When  the  hemorrhage  is 
confined  to  the  anterior  chamber,  and  there  is  no  rupture 
of  any  of  the  external  tunics  of  the  eye,  the  case  gener- 
ally does  well.  The  blood  is  first  macerated  by  the 
aqueous  humor,  and  then  rapidly  absorbed.  In  this,  as 
indeed  in  all  cases  of  injurj^,  rest  to  the  eyes  is  essential: 
all  work  should  for  a  time  be  forbidden,  and  the  e3"es 
should  be  shaded  from  strong  light.     Cold  applications 


118  DISEASES    OF   THE    IRIS. 

are  the  best  suited,  and  afford  the  most  comfort  to  the 
eye.  A  double  fold  of  linen,  wet  with  cold  water,  may  be 
laid  over  the  eye,  and  kept  in  its  place  with  a  single  turn 
of  a  light  roller,  and  moistened  from  time  to  time  with 
a  little  fresh  water  from  a  sponge ;  or,  if  the  eye  be  pain- 
ful, a  cold  lotion  of  belladonna  ma}^  be  used  in  the  i)Iace 
of  the  water-dressing. 

CoREDiALYSis  is  a  detachment  of  the  iris  from  its  ciliary 
border,  bj^  which  a  new  pupil  is  frequently  formed.  It  is 
generally  caused  by  sharp  blows  on  the  eye,  such  as  with 
the  handle  of  a  Avhip,  with  the  cork  from  a  bottle  of  soda 
water,  or  an  accidental  back  blow  from  the  hand  of  an- 
other person,  or  indeed  from  any  sharp  sudden  violence. 
Coredial3'sis  maj^  be  associated  with  rupture  of  the  ex- 
ternal coats  of  the  eye,  but  in  the  majority  of  cases  it  has 
not  this  severe  complication.  The  separation  of  the  iris 
from  its  ciliary  connection  is  always  immediately  followed 
by  free  bleeding,  often  sufHcient  in  quantit}'  to  fill  the 
whole  of  the  anterior  chamber  with  a  bloodclot.  The 
extent  of  the  coredialysis  varies  very  much :  in  some  cases 
the  detachment  is  so  small  as  scarcel3'  to  be  visible  after 
all  the  blood  has  been  absorbed ;  whilst  in  other  instances, 
a  third  or  even  more  of  the  iris  ma}'  be  loosened  from  the 
ciliar}-  body. 

The  pupillary  border  of  the  iris  corresponding  to  the 
dialysis  is  paralyzed  from  a  tearing  through  of  the  ciliarj' 
nerves  which  supply  it,  and  that  part  of  it  is  uninfluenced 
b}^  the  action  of  light  and  shade.  The  complete  circle  of 
the  pupil  is  thus  destroj-ed — a  defect  which  is  most  ob- 
servable when  the  pupil  is  dilated. 

The  Prognosis  of  cases  of  coredialysis  when  there  is  no 
rupture  of  the  external  coats  of  the  e^e  is  favorable.  A 
guarded  opinion  should,  however,  be  always  given,  as  the 


PROLAPSE.  119 

blow  which  has  force  enough  to  cause  a  coredialysis  may 
also  produce  cataract  or  posterior  hemorrhage. 

Treatment. — The  same  as  in  "  hemorrhage  into  the  an- 
terior chamber."     See  preceding  section. 

Prolapse  of  the  Iris. — Penetrating  and  incised 
wounds  of  the  cornea  are  very  generally  immediately 
followed  by  prolapse  of  the  iris.  The  extent  of  the  pro- 
trusion varies  with  the  size  and  the  position  of  the  wound. 
A  small  penetrating  wound  near  the  margin  of  the  cornea 
is  more  likely  to  be  attended  with  a  prolapse,  than  a  large 
incised  one  near  the  centre. 

Prolapse  of  the  iris  is  very  commonly  associated  with 
injury  to  the  lens  ;  but  as  a  rule,  we  have  first  to  direct 
our  attention  in  the  treatment  of  the  case  to  the  prolapsed 
iris,  leaving  the  traumatic  cataract  to  be  dealt  with  at  a 
future  period. 

A  prolapse  of  the  iris  may  be  treated  in  three  different 
ways  : 

1st.  By  a  compress  applied  externally  over  the  closed 
lids. 

2d.  By  removing  with  a  pair  of  fine  scissors  the  pro- 
lapsed iris. 

3d.  By  frequent  puncturings  of  the  prolapsed  iris  with 
a  fine  needle. 

1st.  By  compress. — This  mode  of  treatment  should  be 
adopted  immediately  after  the  accident,  when  it  tends  to 
prevent  an  increased  prolapse  of  the  iris,  keeps  the  eye  in 
a  state  of  rest,  and  effectually  excludes  all  light.  It  may, 
however,  after  a  short  time  have  to  be  abandoned,  or  used 
in  concert  with  other  remedies. 

2d.  Removing  with  a  pair  of  scissors  the  pi'olapsed  Iris 
is  applicable  where  the  prolapse  is  small  and  the  wound  a 
clean  puncture,  made  by  a  fine  sharp  instrument,  and 
without  any  contusion  of  the  corneal  tissue.     This  treat- 


120  DISEASES    OF   THE    IRIS. 

ment  is  especially  beneficial  in  cases  of  pi'olapse  in  the 
upper  half  of  the  cornea,  -when  the  movements  of  the  lid 
over  it  are  prodnctive  of  great  irritation. 

3d.  Frequent  puncturings  of  Prolapse  loith  a  fine 
needle  are  most  useful  in  cases  of  extensive  prolapse  of 
the  iris  near  the  margin  of  the  cornea,  where  there  is  a 
large  wound  with  a  tendency  to  gape,  and  where  it  is 
evident  that  snipping  off  the  prolapsed  iris  would  be  fol- 
lowed by  an  additional  protrusion.  The  prolapse  should 
be  pricked  at  one  or  two  points,  so  as  to  cause  the  aqueous 
to  escape  and  its  sides  to  collapse,  and  at  the  same  time 
to  permit  the  edges  of  the  wound  to  close  upon  it. 

The  general  treatment  must  be  strictly  soothing,  and 
great  care  should  be  taken  of  the  eye  for  at  least  six 
months  after  a  wound  followed  by  prolapse  of  the  iris, 
even  though  the  lens  may  have  escaped  all  injury.  Both 
eyes  should  be  shaded,  and  all  strong  lights  should  be 
carefully  excluded.  The  eyes  should  be  protected  from 
glare  when  ont  of  doors  by  spectacles  with  dark  neutral 
tint  glasses. 

Soon  after  the  accident  two  or  three  leeches  should  be 
applied  to  the  temple  of  the  injured  eye  ;  and  three  or  four 
times  during  the  day  the  eye  should  be  bathed  with  a  bel- 
ladonna lotion  (F.  32)  ;  or  it  may  be  fomented  with  a 
warm  decoction  of  j)Oi3py-heads.  A  few  drops  of  the  so- 
lution of  the  sulphate  of  atropia  gr.  1  ad  aquae  5  1  should 
be  also  dropped  into  the  e^'e  twice  a  day,  as  it  is  of  im- 
portance to  keep  the  eye  under  the  influence  of  belladonna 
for  the  first  two  or  three  daj'^s  at  least  after  the  accident. 
If  a  compress  is  applied  over  the  eye,  it  should  be  re- 
moved three  times  daily,  to  allow  of  the  eye  being  bathed 
with  the  lotion ;  but  if  one  of  the  other  plans  of  treating 
the  prolapse  be  adopted,  in  addition  to  bathing  the  qjq^ 
a  fold  of  linen  wet  with  the  lotion  may  be  laid  over  the 
closed  lids. 


IRIDO-CHOROIDITIS.  121 

No  prolapse  of  the  iris  should  be  very  lightly  regarded ; 
for  I  have  seen  complete  blindness  follow  from  what  has 
appeared  at  first  a  comparatively  slight  injiu-y. 

IRIDO-CHOROIDITIS    AND    CHOROIDO-IRITIS. 

Inflammation  of  the  iris  and  choroid  is  not  a  primary 
disease,  that  is  to  say,  the  two  structures  are  seldom 
simultaneously  affected.  It  is  caused  either  by  the  ex- 
tension of  an  iritis  to  the  adjoining  choroid;  or  by  a 
spreading  of  an  inflammation  of  the  choroid  to  the  iris. 
Two  forms  of  inflammation  of  the  iris  and  choroid  may 
therefore  be  recognized. 

1st.  When  the  disease  commences  with  iritis  and  the 
choroid  is  secondarily  affected.  To  this  form,  the  term 
irido-choroiditis  is  applied. 

,  2d.  When  the  primary  disease  is  in  the  choroid,  and 
the  ii'is  is  secondarily  involved.  To  this  form  the  term 
choroido-iritis  is  applied.  The  prefix  in  each  name  indi- 
cates the  structure  first  affected.  This  classification  is 
important,  as  the  two  diseases  are  not  identical,  but  differ 
both  in  their  progress  and  ultimate  results. 

1st.  Irido-choroiditis  is  an  extension  of  an  inflamma- 
tion from  the  iris  to  the  choroid.  It  is  most  liable  to 
occur  in  ej'es  which  have  had  frequent  recurrences  of 
iritis,  and  where  a  complete  adhesion  has  formed  between 
the  pupillary  margin  and  the  capsule  of  the  lens.  This 
"exclusion  of  the  pupil"  exerts  a  very  prejudicial  influ- 
ence on  the  eye.  The  pupillary  border,  tied  down  by 
synechise  to  the  lens  capsule,  is  repeatedly  pulled  on  by 
the  iris  in  its  abortive  efforts  to  dilate  and  contract  the 
pupil  under  the  influence  of  light  and  shade,  or  in  con- 
cert with  the  action  of  the  iris  in  the  other  eye;  and  thus 
a  constant  source  of  irritation  is  maintained.     The  com- 

11 


122  DISEASES    OF   THE    IRIS. 

munication  between  the  anterior  and  posterior  chambers 
of  the  eye  through  the  pupil  is  ch:)sed,  and  the  proper 
balance  of  fluid  between  them  is  destroyed.  The  aqueous 
consequentl}^  accumulates  in  excess  in  the  posterior  cham- 
ber, and  presses  forward  the  iris  towards  the  cornea,  ren- 
dering its  surface  convex,  and  throwing  into  small  ir- 
regular bulgings  those  portions  of  the  iris  which  have 
undergone  atrophic  changes  from  the  frequent  recur- 
rences of  inflammation. 

S>/mptoms.  —  The  early  symptoms  are  those  of  iritis, 
from  the  first  attack  of  which  the  patient  may  have  re- 
covered ;  but  after  one  or  more  relapses  the  whole  or  the 
greater  part  of  the  margin  of  the  pupil  has  become  bound 
down  by  synechiae,  and  lymph  has  been  effused  on  the 
capsule  of  the  lens  within  the  pupillar}'  area.  The  iris  is 
now  gradually  pushed  forwards  towards  the  cornea  from 
an  accumulation  of  the  aqueous  in  the  posterior  chamber  j. 
its  striation  is  blurred  and  indistinct;  its  surface,  dis- 
colored and  hazy,  is  convex  instead  of  being  plane,  and, 
if  the  disease  has  been  of  long  standing,  it  is  marked  by 
irregular  knotty  bulgings  from  atrophic  portions  yield- 
ing to  the  pressure  of  the  fluid  behind  it.  At  this  stage 
there  is  frequentlj^  a  difliised  opacity  of  the  vitreous  with 
floating  opacities.  The  vision  is  always  greatly  impaired, 
and  especially  in  those  cases  where  the  iris  is  much  arched 
forwards ;  and  occasionally  there  is  considerable  limita- 
tion of  the  field.  The  contracted  pupil,  opacit}'  of  the 
pupillary  portion  of  the  lens  capsule,  and  hazy  vitreous 
prevent  the  ophthalmoscope  from  affording  much  infor- 
mation as  to  the  state  of  the  parts  at  the  fundus  of  the 
eye.  This  must  be  estimated  partly  by  the  general  ap- 
pearance of  the  structures  which  can  be  seen,  but  chiefly 
by  an  accurate  examination  of  the  amount  of  sight  and 
the  extent  of  the  field  of  vision.  During  the  inflamma- 
torj'  attacks  the  tension  of  the  globe  is  apt  to  be  greatly 


GUOROIDO-IRITIS.  123 

increased,  but  in  the  later  stages  of  the  disease  the  eye 
becomes  soft  from  atrophy  of  the  structures  within  it, 

2d.  Choroido-iritis  is  an  inflammation  whicli  com- 
mences in  the  choroid,  and  afterwards  extends  to  the 
iris.  It  is  a  more  severe  affection  than  the  preceding, 
and  less  amenable  to  treatment. 

Symptomi^. — The  early  symptoms  are  failing  sight,  a 
slightly  dilated  and  sluggish  pupil,  and  turbidity  of  the 
vitreous.  There  is  nothing  in  the  external  appearance 
of  the  eye  to  account  for  the  great  impairment  of  sight. 
The  disease  at  this  stage  is  confined  to  the  choroid,  but 
after  a  time  it  gradually'  extends  itself  to  the  iris,  and 
symptoms  of  a  low  form  of  iritis  are  developed.  The 
iritic  sj'mptoms  are  of  a  subacute  form,  and  ver}^  insid- 
ious in  their  progress.  They  are  usuall}^  accompanied 
with  some  irritability  and  redness  of  the  eye,  especially 
in  the  ciliary  region.  The  impairment  of  sight  steadily 
increases,  the  field  of  vision  becomes  contracted,  and  por- 
tions of  it  are  occasionally  destroyed  either  from  partial 
detachments  of  the  retina,  or  from  patches  of  atrophy  of 
both  the  choroid  and  retina.  The  tension  of  the  globe  as 
a  rule  remains  unaltered,  until  during  the  later  stages 
of  the  disease,  when  atrophic  changes  in  the  recently  in- 
flamed structures  cause  the  eye  to  become  soft. 

The  Prognosis  of  irido-choroiditis  is  more  favorable 
than  that  of  choroido-iritis.  In  the  former  the  defect  of 
sight  ma}^  be  chiefl}-  due  to  the  centi-al  opacity  of  the  lens 
capsule,  the  vitreous  being  still  clear,  and  the  choroid  but 
little  affected.  When  such  is  the  case,  there  is  a  good 
prospect  of  the  eye  under  proper  treatment  regaining  use- 
ful vision.  In  choroido-iritis  the  impairment  of  vision  is 
usually  great,  and  clearl}^  dependent  on  changes  at  the 
fundus  of  the  eye.  The  most  hopeful  cases  are  those  in 
which  there  is  a  fair  field  of  vision,  with  an  ability  to  read 


124  DISEASES    OF    THE    IRIS. 

large  type, — and  with  tlie  globe  of  the  normal  tension. 
When  the  eye  is  soft,  the  field  much  contracted,  and  there 
remains  onl}^  an  imperfect  perception  of  light,  the  prog- 
nosis is  ver}^  bad,  for  no  benefit  will  be  derived  by  any 
operative  procedure. 

Treatment. — Although  both  irido-choroiditis  and  cho- 
roido-iritis  may  arise  from  many  causes,  yet  a  large  num- 
ber of  the  cases  of  these  diseases  are  dependent  on  syphi- 
lis. A  careful  inquir}^  should  therefore  be  always  made 
into  the  previous  history  of  the  patient,  as  if  a  syphilitic 
taint  can  be  discovered,  it  forms  a  good  ground  upon 
which  to  found  the  treatment,  and  the  prognosis  is  more 
favorable  than  when  the  source  of  the  disease  cannot  be 
traced.  If  syphilis  is  the  probable  cause,  the  treatment 
recommended  for  Retinitis  Syphilitica,  should  be  fol- 
lowed. If,  however,  the  source  of  the  inflammation  should 
be  due  to  a  rheumatic  diathesis,  the  treatment  advised  for 
Rheumatic  Iritis,  page  99,  should  be  adopted.  No  per- 
manent benefit,  however,  will  be  gained  by  the  mere  use 
of  medicines,  and  soothing  applications  to  the  eye ;  so 
long  as  the  iris  remains  tied  down  to  the  lens  capsule,  and 
the  communication  between  the  anterior  and  posterior 
chambers  is  destroyed,  recurrences  of  the  inflammation 
are  liable  to  occur.  As  soon  therefore  as  the  eye  has  be- 
come free  from  active  irritation,  an  iridectom}-  should  be 
performed  ;  firstly,  with  the  object  of  restoring  the  channel 
through  the  pupil  between  the  anterior  and  posterior 
chambers ;  and  secondly,  for  the  purpose  of  making  an 
artificial  pnpil,  and  exposing  a  portion  of  transparent  lens 
and  capsule,  through  which  the  patient  may  have  better 
vision.  There  are  several  difficulties  which  beset  the  ope- 
ration of  iridectomy  in  these  cases. 

a.  From  the  shallowness  of  the  anterior  chamber,  owing 
to  the  iris  being  pressed  forwards  towards  the  cornea,  it 
is  often  unsafe  to  use  the  triangular-shaped  iridectomy 


CHOROIDO-IRITIS.  125 

knife.  In  such  cases  Graefe's  cataract  knife  should  be 
used  in  the  manner  recommended  in  "  the  operation  of 
iridectom}',"  page  111. 

/5.  In  drawing  out  the  portion  of  iris  through  the  wound 
previous  to  excising  it,  the  pupillary  border  which  is  ad- 
herent to  the  lens  capsule  often  becomes  detached  and 
remains  in  situ.  No  attempt  should  be  afterwards  made 
to  get  it  away,  as  it  in  no  way  interferes  with  the  good 
eflfect  of  the  operation. 

y.  The  iris  may  be  so  rotten,  and  have  formed  such 
broad  adhesions  between  its  posterior  surface  and  the 
lens  capsule,  that  there  may  be  difficulty  in  drawing  out 
a  portion  of  it  with  the  forceps ;  or  after  the  iridectomy 
has  been  completed,  the  sight  may  be  in  no  way  improved 
owing  to  the  exposed  lens  capsule  being  covered  with 
uvea.  In  such  cases  it  is  generally  advisable  to  remove 
the  lens  at  a  future  operation. 

When  it  is  evident  that  broad  and  extensive  adhesions 
exist  between  the  posterior  surface  of  the  iris  and  the  lens 
capsule,  and  that  therefore,  an  iridectomy  would  fail  to 
benefit  the  sight,  the  following  operation,  which  has  been 
frequently  adopted  by  Mr.  Bowman  and  Mr.  Critchett, 
may  be  performed. 

The  lids  being  separated  with  a  spring  speculum,  an 
iridectomy  knife  is  used  to  make  an  opening  at  the  margin 
of  the  cornea,  as  in  an  ordinary  operation  for  iridectomy  ; 
but  the  point  of  it  is  carried  beyond  the  pupil,  and  dipped 
downwards,  so  as  to  make  a  transverse  cut  in  the  iris  just 
below  the  pupil.  The  blades  of  a  pair  of  fine  scissors  are 
then  introduced  through  the  opening  at  the  margin  of 
the  cornea,  one  blade  in  front  of  and  the  other  behind  the 
iris ;  and  a  cut  is  made  first  on  one  side  to  join  one  ex- 
tremity of  the  transverse  slit  below  the  pupil,  and  the 
same  proceeding  is  then  repeated  on  the  other  side  to 
make  a  similar  cut  to  join  the  other  end  of  the  transverse 

11* 


126 


DISEASES    OF   THE   IRIS. 


incision.  The  somewhat  oblong-shaped  piece  thus  in- 
cluded in  the  section  consists  of  iris,  and  a  portion  of  the 
anterior  capsule  of  the  lens  adherent  to  it.  The  piece  is 
then  lifted  awa3^  by  a  pair  of  forceps,  and  the  lens-matter 
behind  removed  by  a  curette  or  cataract-spoon. 


Fig 


The  dotted  lines  in  Fig.  7  represent  the  line  of  the 
incision  at  the  margin  of  the  cornea,  and  the  piece  of  iris 
which  is  afterwards  excised. 


SYMPATHETIC    OPHTHALMIA 

Is  a  peculiar  inflammation  of  one  eye  excited  b}'  some 
special  irritation  in  the  other. 

There  are  two  forms  of  sympathetic  ophthalmia. 

The  first,  from  being  the  slighter  of  the  tAvo,  ma}'  be 
called  sympathetic  irritation. 

The  second  is  the  severe  disease  now  so  well  known  by 
the  name  of  sympathetic  ophthalmia. 


Sympathetic  Irritation  consists  of  attacks  of  extreme 
irritability  of  the  sound  eye,  Avhich  ma}'  come  on  when- 
ever the  lost  or  injured  one  becomes  inflamed.  There  is 
a  slight  indistinctness  of  vision,  the  objects  seem  to  dance 


SYxMPATIIETIC    OPHTHALMIA.  127 

about,  aucl  reading  tires  the  eye.  Tlie  patient  may  be 
able  to  read  No.  1  of  Jaeger,  and  to  see  distant  figures 
rightl}",  but  he  cannot  do  so  for  any  length  of  time,  the 
effort  of  accommodation  soon  fails,  and  the  eye  becomes 
fagged.  During  the  attack  the  eye  is  slightly  reddened, 
watery,  and  irritable:  occasionally^  it  is  painful;  the  pa- 
tient has  neuralgic  shootings  in  it,  and  this  may  then  be 
the  sj'mptom  which  gives  the  greatest  trouble.  The  at- 
tack generally  lasts  for  some  daj's,  or  it  ma}'  even  con- 
tinue for  one  or  two  weeks,  and  then  gradually'  cease ;  the 
recovery  being  frequently  coincident  with  the  cessation 
of  the  irritation  in  the  injured  eye. 

The  points  in  which  sympathetic  irritation  differs  from 
sympathetic  ophthalmia  are : 

1.  Although  the  eye  may  be  subjected  to  frequent  re- 
currences of  the  attacks,  yet  no  fibrinous  effusions  nor 
disorganizing  changes  of  its  different  tissues  take  place. 

2.  The  excision  of  the  lost  or  injured  eye  at  once  arrests 
the  disease.  All  S3^mpathetic  irritation  ceases  when  the 
cause  which  gave  rise  to  it  is  removed. 

Sympathetic  Ophthalmia  is  essentiall}'  an  adhesive 
or  fibrinous  inflammation.  Its  tendency  is  to  rapid  plastic 
effusions,  which  soon  become  organized  and  incapable  of 
absorption — blending  the  different  tissues  together,  im- 
pairing their  textures,  and  destroying  their  functions. 

I  have  never  known  an  e3'e  affected  with  sj'mpathetic 
inflammation  suppurate. 

The  causes  of  sympathetic  ophthalmia  are^ 

1.  Wounds  of  the  e3'e. 

2.  The  lodgement  of  foreign  bodies  within  the  globe. 

3.  The  irritation  excited  b}^  degenerative  changes 
taking  place  in  e^'cs  already  lost. 

Sj'mpathetic  ophthalmia  is  seldom,  if  ever,  excited  by  a 
suppurative  inflammation  of  one  e3'^e.     This  fact  has  been 


128  DISEASES    OF   TUE    IRIS. 

noticed  by  Von  Graefe,  and  my  own  experience  accords 
with  it.  If,  however,  a  foreign  body  is  within  the  globe, 
suppuration  does  not  lessen  the  danger  which  its  presence 
in  the  stump  will  keep  up. 

The  age  of  the  patient  has  a  remarkable  injluence  on 
this  disease. — The  young  are  much  more  prone  to  it  than 
the  old,  and  it  runs  its  course  more  rapidly  in  the  child 
or  the  young  adult  than  it  does  in  the  middle-aged  or  the 
old. 

The  period  at  ivhich  s7/mpathetic  ophthalmia  may  come 
on  after  an  injury. — It  is  difficult  to  assign  any  date  at 
which  sympathetic  ophthalmia  may  be  expected,  or  after 
which  the  sound  ej-e  may  be  considered  as  safe.  So  long 
as  the  irritation  primarily  excited  by  the  injury  continues, 
the  sound  eye  may  sympathize.  The  risk  cannot  be  said 
to  have  passed  awa}^  until  the  injured  e^^e  has  quite  re- 
covered ;  the  sclerotic  must  have  gained  its  normal  white- 
ness, and  all  photophobia  and  lachrymatiou  have  ceased. 

Tension  of  the  Eye. — The  tension  of  a  s^nnpathetically 
inflamed  eye  varies  with  the  development  of  the  disease. 
In  the  early  stages  it  is  usually  increased,  sometimes  to 
the  extent  of  T  2  or  3,  so  that  the  globe  cannot  be  in- 
dented with  the  fingers.  This  state  of  increased  tension 
may  continue  during  many  months,  or  even  last  bej'ond 
a  year.  It  may  accompany  the  acute  or  subacute  symp- 
toms which  precede  atroph3^  If  the  disease  runs  on  un- 
abated and  unarrested,  the  increased  tension  subsides, 
and  the  eye  gradually  becomes  softer  than  normal,  and 
sinks  to — T  2  or  3.  The  vitreous  slowly  atrophies,  loses 
consistency  and  diminishes  in  bulk,  and  with  these 
changes  the  eye  softens.  But,  woi'st  of  all,  as  the  atrophy 
of  the  vitreous  proceeds,  the  retina  is  deprived  of  its  nor- 
mal support,  and  falling  forwards  becomes  parti}'  or  com- 
pletely detached. 

Symptoms At  the  commencement  of  the  attack,  the 


SYMPATHETIC  OPHTHALMIA.  129 

eye  is  irritable  and  abnormally  sensitive  to  light;  there 
is  some  lachrj'mation,  the  conjnnctiva  is  a  little  injected, 
and  the  pupil  is  decidedly  sluggish  in  its  action ;  the 
power  of  focusing  the  eye  for  near  objects  is  diminished  ; 
and  the  patient  is  unable  to  maintain  a  prolonged  accom- 
modative effort.  Reading  or  any  fine  work  quickly  in- 
duces a  fatigue  which  is  followed  first  by  the  words  be- 
coming confused  and  blurred,  and,  lastly,  if  the  eyes  are 
not  rested,  by  a  complete  loss  of  their  image.  A  few 
minutes'  rest  and  the  eye  can  resume  its  work,  but  the 
same  symptoms  shortly  reappear  and  oblige  it  to  desist. 

If  the  disease  progresses,  the  globe  from  sclerotic  in- 
jection assumes  a  pinkish  appearance,  with  a  distinct 
ciliary  zone  around  the  cornea,  showing  internal  conges- 
tion. The  pupil  contracts  adhesions  to  the  anterior  cap- 
sule of  the  lens,  and  becomes  stationary ;  or  if  atropine 
is  dropped  into  the  eye,  it  dilates  only  slightly,  irregu- 
larl^',  and  partially.  The  aqueous  becomes  serous,  and 
the  striation  of  the  iris,  at  first  indistinct,  is  afterwards 
completely  lost. 

At  the  onset  of  the  disease  there  is  generally  no  pain^ 
not  even  sufficient  to  draw  proper  attention  to  the  eye ; 
but  in  the  later  stages  the  globe  is  tender  to  the  touch, 
and  there  is  frequently  supra-orbital  pain.  Lymph  is 
speedily  effused  in  large  quantities  as  an  infiltration  into 
the  difterent  tissues  involved  in  the  inflammation  ;  the 
pupillary  area  of  the  capsule  of  the  lens  is  covered  and 
the  iris  almost  soaked  Avith  it.  This  exudation  rapidly 
becomes  organized,  and  contracts  firm  adhesions  between 
the  posterior  surface  of  the  iris  and  the  lens  capsule. 
Commencing  generally  in  the  iris,  the  disease  extends 
itself  back  to  the  choroid,  and  a  form  of  irido-choroiditis 
is  established,  very  difficult  to  arrest. 

Earl}'  in  the  disease,  when  the  iris  is  saturated  with 
1}  mph,  it  is  soft  and  rotten  ;  but  at  a  later  date,  when  all 


130  DISEASES    OF   THE    IRIS. 

the  acute  symptoms  have  passed  awaj',  the  iris  has  be- 
come completely  changed  in  its  character;  it  is  exces- 
sively tough,  has  completely  lost  all  its  elasticity,  and  is 
converted  into  a  dense  fibrous  membrane. 

Treatment. — In  the  treatment  of  s^-mpathetic  inflam- 
mation of  the  eye,  we  must  consider — firstl}',  how  to 
arrest  the  progress  of  the  disease ;  and,  secondly,  how 
to  deal  with  an  eye  which  remains  damaged  after  the  dis- 
ease has  been  arrested. 

1.  Hoio  to  arrest  the  progress  of  the  disease. — If  the 
sympathetic  inflammation  of  one  eye  is  dependent  on  in- 
jur}' to  the  other,  and  it  is  clear  that  the  wounded  eye  is 
irreparably  blind  ;  or  if  the  exciting  cause  of  the  mischief 
is  a  previously  lost  eye  becoming  inflamed,  then  there 
cannot  be  a  moment's  hesitation  about  the  propriety  of 
at  once  extirpating  the  diseased  or  the  injured  eye. 

The  importance  of  removing  at  an  earl}^  period  an  eye 
which  has  been  so  injured  as  to  be  useless,  and  which  is 
exciting  irritation  in  the  other,  or  the  inflamed  remnant 
of  a  lost  ej'e  which  is  acting  in  the  same  prejudicial  man- 
ner, cannot  be  exaggerated ;  for  though  in  the  very  early 
stage  of  sjanpathetic  ophthalmia  the  removal  of  the  cause 
of  irritation  will  and  generally  does  cause  its  subsidence, 
3'et  when  the  disease  has  thoroughl}-  taken  hold  of  the 
sound  ej^e,  even  the  removal  of  the  lost  one  ma}'  fail  to 
arrest  its  progress. 

General  Treatment. — Absolute  rest  to  the  eyes  is  im- 
peratively demanded  ;  all  reading,  writing,  or  fine  work 
of  any  kind,  must  be  forbidden  ;  when  at  home,  the  room 
should  be  kept  darkened,  and,  when  out,  dark  neutral- 
tinted  glass  goggles  should  be  worn.  It  is  impossible  to 
overrate  the  imi^ortance  of  keeping  the  patient  for  a  long 
period  in  a  very  subdued  light ;  it  affords  the  best  hope 
of  success,  and  places  the  eyes  in  a  position  to  receive 
most  favorably  the  influence  of  any  other  treatment  which 


SYMPATHETIC   OPHTHALMIA.  131 

ma}^  be  adopted.  However  well  the  patient  ma^'  progress, 
the  order  to  rest  the  ej'es  and  abstain  from  work  should 
not  be  rescinded  for  at  least  from  six  to  eight  months. 
The  disease  is  very  recurrent  in  its  nature,  and  the  too 
soon  exposing  the  eyes  to  the  stimulus  of  strong  light 
will  increase  the  chances  of  relapse. 

The  patient  should  be  well  fed,  as  the  disease  is  ver}' 
depressing,  and  tonics  of  quinine,  iron,  or  bark,  should 
be  prescribed.  I  have  occasionally  found  the  mineral 
acids  with  tincture  of  nux  vomica  (F.  60)  do  good.  From 
the  use  of  iodide  of  potassium  and  perchloride  of  mer- 
cury, both  of  them  favorite  medicines  in  the  treatment 
of  irido-choroiditis,  I  have  never  known  the  slightest 
benefit. 

In  some  cases  I  have  seen  decided  impi'ovement  from 
a  moderate  inunction  of  mercury,  but  quinine  in  one-  or 
two-grain  doses  must  be  given  at  the  same  time. 

Local  Applications. — Belladonna  in  one  form  or  another 
affords  the  most  grateful  application  to  the  eyes.  A  solu- 
tion of  atropine,  of  the  strength  of  one  grain  to  the  ounce, 
should  be  dropped  into  the  eyes  three  or  four  times  a  day. 
It  is  a  direct  and  very  excellent  sedative  to  the  eye,  allays 
irritability  and  relieves  pain,  and  sometimes  it  seems  to 
exert  almost  a  specific  action  on  the  disease.  The  fre- 
quent use  of  a  belladonna  lotion  (F.  32)  also  gives  great 
comfort. 

No  operation  should  be  performed  either  with  the  view 
of  arresting  the  disease,  or  for  the  purpose  of  making  an 
artificial  pupil  so  long  as  the  eye  is  inflamed. 

2.  How  to  deal  ivith  an  eye  which  remains  damaged 
after  the  disease  has  been  arrested. — If  the  disease  has 
been  stayed  before  the  deeper  parts  of  the  eye  have  been 
seriously  implicated,  and  a  fair  perception  of  light  re- 
mains, much  may  be  done  by  operative  treatment  to  re- 
store useful  vision  to  the  eye.     The  objects  to  be  attained 


132  DISEASES    OF   THE    IRIS. 

are,  the  formation  of  a  new  pupil,  and  the  extraction  of 
the  lens.  There  are  very  few  e^'es  which  have  suffered 
from  sympathetic  ophthalmia  in  which  an  artificial  pupil 
can  be  satisfactorily  made  without  at  the  same  time  re- 
moving the  lens.  The  iris  has  become  so  changed  in 
structure,  and  so  adherent  to  the  lens  capsule,  that  it  is 
difficult  and  often  impossible  to  perform  an  iridectomy  ; 
and  even  when  this  can  be  accomplished,  it  usually  fails 
to  benefit  the  sight,  from  the  exposed  capsule  of  the  lens 
being  coated  with  uvea.  It  is,  therefore,  generally  ad- 
visable to  endeavor  to  remove  a  portion  of  iris  and  to  ex- 
tract the  lens  in  the  one  operation.  To  eflfect  this,  one  of 
two  proceedings  ma}^  be  adopted.  The  operation  recom- 
mended in  the  treatment  of  irido-choroiditis,  page  125, 
may  be  performed ;  or  the  one  which  has  been  recently 
practised  b}^  Mr.  Bowman,  of  first  excising  a  triangular 
portion  of  iris  and  adherent  lens  capsule  with  a  pair  of 
scissors,  and  then  extracting  the  lens.  See  Artificial 
Pupil  by  Excision  of  a  triangular-shaped  piece  of 
Iris,  page  116. 

The  extraction  of  the  lens  seems  to  exert  a  beneficial 
influence  on  the  eye,  as  after  it  has  recovered  from  the 
effects  of  the  operation,  it  is  much  less  diposed  than  it 
was  before  to  a  recurrence  of  the  inflammation. 

glaucoma. 

There  are  three  forms  of  this  disease : 

1.  The  acute  and  subacute  inflammatory. 

2.  The  chronic  or  simple. 

3.  The  consecutive  or  secondar3\ 

The  characteristic  sj^mptoms  of  all  are,  increased  ten- 
sion of  the  globe,  impairment  of  the  field  of  vision,  and 
fading  sight.     The  progress  of  each  diflfers,  but  if  unin- 


GLAUCOMA.  133 

terrupted  by  treatment,  the  end  is  the  same — sooner  or 
later  irreparable  blindness. 

To  ascertain  the  tension  of  the  globe. — See  page  140. 

The  impairment  of  the  field  of  vision  in  glancoma  is 
veiy  great.  It  usually  commences  at  the  inner  or  nasal 
side,  at  which  part  it  is  sometimes  completely  wanting. 
In  some  cases  the  field  is  simply  contracted,  and  this 
occasionally  goes  on  to  such  an  extent,  that  the  patient 
will  describe  his  limitation  of  vision  "  as  if  he  were  look- 
ing through  a  tube."  In  other  cases  portions  of  the  field 
are  completely  obliterated,  so  that  in  certain  directions 
the  eye  is  blind. 

To  determine  and  viop  out  the  field  of  vision. — See 
article  on  this  subject. 

Causes. — Glaucoma  is  a  disease  of  advanced  life,  the 
large  majority  of  the  cases  being  in  jjatients  over  forty- 
five  years  of  age.  There  are,  however,  exceptional  in- 
stances in  which  it  has  occurred  at  a  much  earlier  date. 
Glaucoma  may  be  idiopathic,  that  is,  it  may  develop  itself 
in  an  eye  without  any  apparent  cause ;  or  it  may  be  de- 
pendent on  an  injur^^,  or  on  some  form  of  inflammation 
of  the  eye  to  which  it  is  secondary. 

The  advent  of  an  attack  of  acute  glaucoma  seems  to  be 
sometimes  due  to  a  sudden  mental  shock  occurring  to  a 
person  already  depressed  and  with  eyes  probably  predis- 
posed to  the  disease.  Thus  I  have  on  several  occasions 
seen  it  come  on  after  severe  affliction  caused  by  the  death 
of  near  relations,  or  by  great  pecuniary  loss.  In  one  case 
which  came  under  my  notice,  a  sudden  fright  in  a  patient 
exhausted  b}"  night  watching,  apparently  induced  the  dis- 
ease. The  patient,  a  nurse,  had  from  sheer  fatigue  fallen 
asleep  by  the  bedside  of  the  patient  she  was  watching, 
when  she  was  suddenly  awoke  in  the  night  by  the  snap- 
ping of  the  sash  cord,  and  the  sudden  falling  of  the  win- 
dow.    Within  a  few  hours  she  had  an  attack  of  acute 

12 


134  DISEASES    OF   THE    IRIS. 

glaucoma.  Patients  who  have  suffered  from  gout  or  from 
disorders  of  the  digestive  system  have  been  supposed  to 
be  specially  liable  to  glaucoma,  but  this  has  not  been 
satisfactorily  proved.  Both  ej'es  ma}^  be  simultaneously 
involved ;  but  it  is  more  usual  for  one  to  be  first  affected, 
and  for  the  disease  to  follow  in  the  other  after  a  varj'ing 
interval.  When  one  eye  has  suffered  from  glaucoma,  the 
other  is  specially  liable  to  be  attacked. 

The  j^remonitory  symptoms  are,  rapidly  increasing 
presbyopia^  the  patient  finding  it  necessary  to  frequently 
change  his  convex  glasses  for  stronger  ones  on  account  of 
his  defect  of  sight  increasing.  Periodic  obscurations, 
sudden  dimness,  varying  in  degree  and  lasting  from  a 
few  minutes  to  several  hours.  Halos  or  rainbows  around 
the  candle  or  an}^  other  light  is  a  frequent  sjmptom,  and 
one  which  generally  draws  the  patient's  attention  to  his 
ej'e.  Diminution  of  the  field  of  vision  and  fading  sight ; 
and  lastly,  a  gradual  increasing  hardness  of  the  globe. 
Such  are  the  warning  symptoms  of  glaucoma,  but  they 
may  be  all  so  slight,  or  may  make  their  appearances  so 
slowl}"  that  they  may  be  unheeded,  and  this  is  especially 
the  case  if  one  eye  onl}'  is  affected. 

AcLTE  Inflammatory  Glaucoma  is  generally  sud- 
den in  its  attack,  occurring  usually  in  ejes  which  have 
had  premonitory  symptoms,  though  they  may  not  have 
been  appreciated  by  the  patient ;  or  it  may  supervene  on 
the  simple  form  of  the  disease,  the  chronic  glaucoma 
rapidly  and  suddenly  assuming  the  acute  inflammatorj- 
type. 

Symptoms. — The  eye  exhibits  all  the  external  manifes- 
tations of  great  internal  congestion  and  acute  inflamma- 
tory action.  There  is  distension  of  the  ciliary  vessels, 
both  of  the  veins  which  emerge  through  the  sclerotic  in 
front  of  the  insertion  of  the  recti,  and  of  the  zone  of 


GLAUCOMA.  135 

arteries  around  the  cornea ;  occasional!}'  there  is  also 
chemosis  of  the  conjunctiva.  The  anterior  chamber  is 
diminished  in  size,  sometimes  to  such  a  degree  as  to  bring 
the  iris  almost  into  contact  with  the  cornea ;  the  pupil  is 
dilated  and  either  very  sluggish  or  completely  inactive. 
The  patient  sees  rainbows  or  halos  of  bright-colored  light 
around  the  candle  or  gaslights.  The  field  of  vision  is 
diminished,  or  parts  of  it  are  obliterated.  The  sight  is 
greatly  impaired,  and  is  rapidly  getting  worse ;  in  a  few 
hours  it  may  be  so  reduced  as  to  be  able  only  to  distin- 
guish Xo.  XX,  or  to  count  fingers.  The  tension  of  the 
globe  is  increased  from  T  1  to  T  3,  or  stony  hardness. 
The  pain  is  usually  most  severe,  oftentimes  of  an  almost 
maddening  character.  There  is  a  sense  of  aching  and 
tightness  of  the  globe,  with  pain  extending  around  the 
orbit,  along  the  side  of  the  head,  and  down  the  nose,  but 
the  most  acute  agonj^  is  often  referred  to  the  back  of  the 
head.  This  is  usually  accompanied  with  severe  vomiting, 
so  as  to  give  to  the  symptoms  an  aspect  of  a  severe  bilious 
attack,  for  which  indeed  it  is  unfortunately  too  often  mis- 
taken. 

Examined  with  the  Ophthalmoscope  the  vitreous  may 
be  so  turbid  as  to  preverft  the  fundus  from  being  seen ; 
but  if  the  humors  are  still  sufficiently  clear,  there  will  be 
found  a  cupping  of  the  optic  nerve,  with  pulsation  of  the 
retinal  vessels,  either  spontaneous,  or  produced  by  the 
slightest  pressure  on  the  globe.  Small  blood-spots  will" 
be  often  seen  scattered  at  different  parts  of  the  retina. 
They  are  the  result  of  capillary  hemorrhages,  which  take 
place  in  most  cases  of  the  acute,  and  in  many  of  the 
chronic  glaucoma.  Filmy  blood-clots  are  also  often  found 
in  the  vitreous. 

The  Characteristics  of  a  Glaucomatous  Cup. — Its  mar- 
gin is  abrupt,  sharp,  and  sometimes  excavated,  and  the 
vessels  as  they  curl  over  its  edge  appear  to  be  either  in- 


136  DISEASES    OF   THE    IRIS. 

terrupted  or  distorted.  If  the  excavation  is  deep^  the 
continuity  of  the  vessels,  as  they  ascend  the  side  of  tlie 
cup  and  mount  over  its  edge,  seems  to  be  lost,  and  the 
vessels  look  as  if  the}^  were  interrupted  or  broken  in  their 
course ;  whilst  if  the  cupping  of  the  nerve  is  shallow,  the 
vessels  appear  bent  or  distorted  as  they  pass  over  its 
edge.  The  optic  disc  is  encircled  b}'  a  light-colored  zone. 
This  is  caused  by  the  edge  of  the  sclerotic  ring  shining 
through  a  rim  of  atrophied  choroid,  and  it  is  best  seen  in 
those  cases  where  the  excavation  is  deepest.  The  central 
portion  of  the  papilla  has  often  a  peculiar  bluish-gray 
tinge  which  increases  in  intensity  towards  the  circum- 
ference of  the  nerve.  So  deceptive  is  the  appearance  of  a 
deeply  excavated  uerxe  that  it  resembles  more  the  promi- 
nence of  a  sphere,  than  the  hollow  of  a  cup.  This  illusion 
is,  however,  at  once  corrected  by  the  apparently  discon- 
nected or  distorted  vessels.  The  glaucomatous  excava- 
tion is  perfectly  distinct  from  what  is  termed  the  physio- 
logical cup).  This  latter  is  simplj-  a  shallow  depression 
confined  to  the  centre  of  the  optic  disc,  in  the  site  where 
the  retinal  vessels  pass  ;  it  looks  white  and  glistening,  and 
its  sides  are  usually  bevelled  or  sloping  ;  it  varies  greatly 
in  size,  but  it  is  surrounded  by  healthy-looking  nerve- 
structure  ;  it  is  congenital,  and  has  no  unfavorable  omen. 
In  addition  to  these  two,  there  is  a  third  form  of  excava- 
tion of  the  disc  produced  by  atrophy  of  the  optic  nerve. 
See  Atrophy  of  Optic  Nerve. 

Two  modifications  of  this  acute  form  of  glaucoma 
should  be  noticed.  A  subacute  in  which  all  the  symptoms 
are  diminished  in  intensity ;  and  a  hemorrhagic  form  in 
which  there  is  a  peculiar  tendenc}'  to  retinal  hemorrhages, 
and  in  which,  bleeding  between  the  choroid  and  retina 
will  sometimes  occur  immediately  the  tension  of  the  globe 
is  relieved  by  iridectomy. 

Results The  vision  maybe  reduced  to  a  mere  percep- 


GLAUCOMA.  137 

tiou  of  large  objects  in  a  few  daj's,  or,  in  very  acute  cases, 
as  in  the  "  Glaucoma  fulminans  "  of  Graefe,*  in  even  a 
few  hours.  If  the  acute  symptoms  subside,  and  some  of 
the  lost  sight  is  regained,  the  eye  is  still  left  in  a  ver}'^  un- 
healthy and  unsatisfactory  state.  The  sight  remains  im- 
paired, the  tension  of  the  globe  will  generally  continue 
too  great,  and  there  is  a  probability,  amounting  almost  to 
a  certainty,  that  the  eye  will  sooner  or  later  be  subjected 
to  another  attack  which  will  still  further  damage  the  sight, 
if  it  does  not  altogether  destroy  it.  After  one  or  more 
of  these  acute  attacks,  the  eye  will  drift  into  that  state  of 
hopeless  blindness  which  has  been  described  as  glaucoma 
absolutum.  It  is,  in  fact,  the  last  stage  of  the  disease, 
when  the  eye  is  irremediably^  blind,  and  when  all  hope  of 
benefit  from  treatment  has  passed.  The  globe  is  of  stony 
hardness,  the  j)upil  widely  dilated,  and  often  irregularly 
so ;  the  anterior  chamber  is  so  shallow  that  the  iris  is 
almost  in  contact  with  the  cornea,  which  is  anaesthetic 
and  dull  in  appearance,  having  lost  much  of  its  normal 
lustre.  The  humors  are  turbid,  so  that  the  fundus  can- 
not be  seen ;  and  it  may  be  that  the  lens  is  also  catarac- 
tous.  But,  in  addition,  the  eye  is  often  subject  to  severe 
pain,  which  is  either  constant  or  so  frequently'  recurring 
as  to  destroy  sleep  and  impair  health.  One  source  of  the 
suffering  is  the  repetition  of  the  acute  inflammatory  at- 
tacks, which  continue  even  though  the  eye  is  lost.  But 
another  cause  of  the  pain  which  is  so  often  continuous,  is 
to  be  found  in  the  irritation  which  is  excited  by  the  de- 
generative changes  which  are  taking  place  in  the  tissues 
within  the  globe. 

Treatment. — For  the  acute  inflammator}-  glaucoma, 
there  is  but  one  plan  of  treatment  which  holds  out  the 
promise  of  regaining  much  of  the  lost  sight,  and  at  the 

*  Archiv  fur  Ophthal.  viii,  2. 
12* 


138  DISEASES    OF    THE    IRIS. 

same  time  of  relieving  pain,  and  that  is  iridectomy.  The 
results  of  this  operation  in  acute  glaucoma  have  been 
most  brilliant;  its  curative  effect  is  now  an  established  fact, 
and  cannot  be  controverted  by  ignorance  or  prejudice. 

To  Yon  Graefe  is  to  be  ascribed  the  honor  of  having 
originated  the  operation,  and  the  thanks  of  all  who  are 
benefited  b}'  it  are  due  to  him.  The  effect  of  iridectomy 
is  to  relieve  tension,  and  the  symptoms  which  are  de- 
pendent on  it  at  once  begin  to  subside.  The  operation 
should  be  performed  as  soon  as  possible  after  the  acute 
sj^mptoms  have  set  in,  as  every  hour  tends  to  diminish 
the  chances  of  recovery. 

Chronic,  or  Simple  Glaucoma. — The  progress  of  this 
disease  is  usually  unaccompanied  by  pain.  It  may  in- 
volve one  or  both  eyes ;  but  when  both  are  affected,  it  is 
genex'ally  more  advanced  in  one  eye  than  in  the  other. 
The  vision  gradually  fades,  and  there  are  occasional  ob- 
scurations in  which  the  dimness  is  greatly  increased — in 
some  cases  almost  to  darkness ;  but  after  a  varying  time 
the  sight  is  regained.  The  patient  sees  rainbows  or  halos 
of  colored  light  around  the  caudles.  The  pupil  is  slug- 
gish and  more  dilated  than  normal.  The  anterior  cham- 
ber becomes  shallow,  and  the  humors  turbid.  The  ten- 
sion of  the  eye  is  increased ;  and  the  field  of  vision  is  con- 
tracted, or  in  parts  lost.  These  symptoms  may  steadily 
progress,  with  occasional  remissions  or  exacerbations, 
until  all  sight  is  extinguished.  Frequently,  however,  an 
acute  attack  supervenes,  and  all  the  sjmptoms  which 
characterize  the  acute  inflammator}'  glaucoma  are  at  once 
developed. 

Examined  with  the  ophthalmoscope  the  same  appear- 
ances are  presented  which  were  mentioned  in  the  section 
on  Acute  Glaucoma,  page  135 ;  viz.,  cupping  of  the  optic 
disc  with   pulsation  of  the  retinal  vessels,  either  spon- 


GLAUCOMA.  139 

taneous  or  produced  under  the  slightest  pressure  of  the 
fingers  on  the  globe ;  turbidit}'  of  the  vitreous,  and  occa- 
sionally small  extravasations  of  blood  on  the  retina. 

Treatment. — Iridectomy  affords  the  best  chance  for  the 
eye ;  but  the  results  of  this  operation  in  the  chronic  or 
simple  glaucoma  are  not  near  so  favorable  as  when  per- 
formed for  the  acute  form  of  this  disease.  It  will  gener- 
ally arrest  the  progress,  and  retain  for  the  patient  the 
vision  he  still  has,  but  it  will  often  fail  to  bring  back  the 
sight  which  has  been  lost.  Still,  so  long  as  the  e3'es  pos- 
sess perception  of  light,  it  is  worth  performing  iridectomy, 
as  the  results  of  the  operation  will  often  far  exceed  the 
expectations,  and  especiall}^  if  the  disease  has  been  of 
short  duration.  In  some  cases  which  have  been  under 
my  care,  where  the  vision  was  so  reduced  that  the  pa- 
tients could  onlj'^  count  fingers,  I  have  been  gratified  by 
such  a  restoration  after  the  operation  as  has  enabled  them 
to  read  fair-sized  tj^^e,  such  as,  from  No.  6  to  Xo.  10  of 
Jaeger. 

The  cases  of  chronic  glaucoma  which  hold  out  the  best 
promise  of  success  are  those  in  which  the  field  of  vision 
is  still  entire,  and  where  the  disease  has  not  continued 
long  enough  to  produce  severe  atrophic  changes  in  the 
optic  nerve  and  retina. 

Consecutive  or  Secondary  Glaucoma  may  compli- 
cate many  of  the  diseases  and  injuries  of  the  eye.  It 
may  follow  a  perforating  wound  in  which  the  lens  has 
been  injured ;  or  it  may  come  on  after  a  needle  operation 
for  cataract  or  for  opaque  capsule ;  or  after  a  dislocation 
of  the  lens  into  the  anterior  or  vitreous  chambers.  It  is 
then  known  as  traumatic  glaucoma  (see  page  179).  Sec- 
ondary'' glaucoma  is  also  occasionally  met  with  in  cases 
of  iritis,  and  irido-choroiditis,  in  staphyloma,  in  sympa- 
thetic ophthalmia,  and  in  some  forms  of  deep  ulceration 


140  DISEASES   OF   THE   IRIS. 

of  the  cornea.     Whenever  it  occurs,  it  must  always  be 
regarded  as  a  grave  symptom. 

Treatment. — In  those  cases  where  the  increased  tension 
of  the  globe  is  dependent  on  removable  causes,  the  source 
of  the  irritation  should  be  taken  away.  Where  a  wounded 
or  broken  up  lens  is  pressing  upon  the  iris,  and  exciting 
glaucomatous  symptoms,  it  should  be  either  sucked  out 
with  a  syringe  or  removed  by  linear  extraction.  When 
a  dislocated  lens  is  the  cause  of  irritation,  it  should  be 
extracted.  In  cases  of  increased  tension  after  capsular 
operations,  paracentesis  of  the  cornea  will  generally  afford 
relief.  (See  page  52.)  The  same  operation  ma}'  be  also 
tried  when  glaucomatous  s^^mptoms  are  associated  with 
deep  ulceration  of  the  cornea ;  but  should  it  fail  to  dimin- 
ish the  tension,  a  portion  of  the  iris  should  be  excised  by 
iridectomy.  In  iritis  or  irido-choroiditis  with  increased 
tension  of  the  globe,  iridectomy  should  be  performed. 

To  ASCERTAIN  THE  TENSION  OF  THE  Globe,  the  patient 
should  be  told  to  gently  close  his  eyes  and  look  down- 
wards Avhilst  the  surgeon  places  his  two  forefingers  on  the 
upper  part  of  the  eye,  and  by  an  alternating  pressure 
Muth  first  one  finger  and  then  the  other,  as  if  feeling  for 
fluctuation,  he  determines  the  degree  of  tightness  of  the 
globe.  The  tension  of  eyes  varies  considerably  in  difler- 
ent  patients  even  in  health ;  it  is  well,  therefore,  when  de- 
ciding on  the  degree  of  tension  of  a  diseased  eye,  to  ex- 
amine also  the  sound  one  so  as  to  compare  the  two,  as 
their  normal  condition  may  be  either  slightl}^  above  or 
below  the  usual  standard  of  tightness. 

The  following  s^-mbols  were  suggested  by  Mr.  Bowman, 
in  the  British  Medical  Journal,  October  11,  18G2,  for  re- 
cording accurately  the  varying  degrees  of  increase  and 
diminution  of  tension : 

"T  represents  te)isio7i  ('t'  being  commonly  used  for 


TREMULOUS    IRIS.  141 

'tangent,'  the  cnpital  T  is  to  be  preferred);  Tn,  fcnsion 
normah  The  interrogative,  ?,  marks  a  doubt,  which  in 
snch  matters  we  must  often  be  content  with.  The  nume- 
rals folloAving  tlie  letter  T  on  the  same  line  indicate  the 
degree  of  incr-eased  tension  ;  or,  if  the  T  be  preceded  l)y 
— ,  of  diminhhed  tension^  as  further  explained  below. 
Thus : 

"  T  3.  Third  degree,  or  extreme  tension.  The  fingers 
cannot  dimple  the  e3'e  by  firm  pressure. 

"T  2.  Second  degree,  or  considerable  tension.  The 
fingers  can  slightly  impress  the  coats. 

"  T  1.  First  degree.  Slight  but  positive  increase  of 
tension. 

"  T  1  ?  Doubtful  if  tension  increased. 

"  Tn.  Tension  normal. 

"  ■ —  T  1  ?  Doubtful  if  tension  be  less  than  natural. 

" —  T  1.  First  degree  of  reduced  tension.  Slight  but 
positive  reduction  of  tension. 

" —  T  2\  Successive  degrees  of  reduced  tension,  short 

" —  T  si  of  such  considerable  softness  of  the  eye  as 
allows  the  finger  to  sink  in  the  coats.  It  is  less  easy  to 
define  these  b}'  words." 

Tremulous  Iris — Iridodonesis — are  terms  applied  to 
an  iris  which  trembles  and  vibrates  with  each  movement 
of  the  e^'c.  It  is  most  frequently  caused  b}'  the  loss  of 
the  lens,  and  is  thus  occasionally  seen  after  the  extrac- 
tion of  cataract,  or  it  may  be  produced  by  a  partial  or 
complete  dislocation  of  that  structure  either  into  the  ante- 
rior chamber  or  vitreous.  The  iris  is  also  generall}^  trem- 
ulous in  cases  of  hydrophthalmos,  owing  to  the  loss  of 
the  lens  from  an  increase  in  the  size  of  the  posterior 
aqueous  chamber,  and  a  stretching  of  the  suspensory 
lioament. 


142  DISEASES    OF   THE    IRIS. 

CoLOBOMA  OF  THE  Iris  is  a  congenital  cleficienc}'  of  a 
portion  of  the  iris,  caused  by  an  arrest  of  development 
in  early  foetal  life.  It  usually  occurs  in  the  lower  part  of 
the  iris,  and  is  associated  with  a  similar  defect  in  the 
choroid.  A  case  is  reported  by  Mr.  Hulke,*  in  which 
there  was  a  coloboma  of  the  iris,  choroid,  retina,  and  op- 
tic nerve-sheath.  Coloboma  of  the  iris  most  frequentlj'^ 
occurs  in  both  eyes,  but  it  is  not  uncommon  to  find  only 
one  eye  affected.  It  is  occasionally  associated  with  mi- 
crophthalmos or  congenitally  stunted  eyes.  Mr.  White 
Cooper  has  related  the  history  of  three  children,  out  of  a 
famil}^  of  seven,  each  of  whom  were  afflicted  with  microph- 
thalmos and  coloboma  of  the  iris  in  both  eyes-f 

DISEASES    OF    THE    VITREOUS    HUMOR. 

ITyalitis,  or  inflammation  of  the  vitreous,  rarely  occurs 
either  as  an  idiopathic  or  a  primary  affection.  It  is  usually 
associated  either  with  disease  of  the  iris,  the  choroid,  or 
retina,  to  which  it  is  secondary.  It  may  be  induced  by 
an  injury,  and  especially  the  lodgement  of  a  foreign  body 
in  the  vitreous  or  the  adjoining  ciliar}^  processes. 

The  inflammation  may  be  either  simple  or  suppurative. 

In  simjile  hyalitis  there  is  a  diffused  haziness  of  the 
vitreous,  with  here  and  there  small  filmy  opacities.  These 
may  be  caused  by  portions  of  the  connective  tissue  be- 
coming opaque,  or  by  small  effusions  of  lymph  into  the 
vitreous  from  the  neighboring  ciliary  processes.  When 
the  hyalitis  is  due  to  the  presence  of  a  foreign  body  within 
the  e3^e,  large  masses  of  l^nnph  will  be  frequently  seen 
behind  the  edge  of  the  lens  projecting  into  the  vitreous, 
whilst  the  rest  of  its  structure  is  so  turbid  as  to  exclude 
the  fundus  of  the  e3'e  from  ophthalmoscopic  view.    If  the 

*  lloyal  London  Opbtlialniic  Hospital  Reports,  vol.  iii,  p.  835. 
t  Ibid.  vol.  i,  p.  110. 


OPACITIES    OF   THE   VITREOUS.  143 

inflammation  is  long  contiuiiecl,  the  vitreous  loses  its  con- 
sistency, and  becomes  more  or  less  fluid  and  reduced  in 
bulk.  With  this  diminution  of  volume  detachment  of  the 
retina  and  shrinking  of  tiie  globe  are  apt  to  occur. 

Suppurative  hyalttis  is  met  with  in  ophthalmitis  and 
suppuration  of  the  globe.  The  efiusion  of  pus  may  be 
often  seen  to  commence  in  the  ciliary  region  behind  and 
to  one  side  of  the  lens,  but  it  soon  diff'uses  itself  through- 
out the  whole  of  the  vitreous. 

Treatment. — As  hyalitis  is  seldom  a  primary  aflfection, 
the  treatment  for  it  will  be  found  under  the  heading  of 
the  diseases  to  which  it  is  secondary. 

MUSC^   YOLITANTES:    OPACITIES    OF    THE   YiTREOUS. 

Opacities  of  the  vitreous,  the  result  of  disease,  must  be 
distinguished  from  the  motes  or  muscse  volitantes,  which 
are  perfectly  compatible  with  healthy  eyes,  although  they 
are  the  source  of  much  anxiety  and  even  of  misery  to  the 
patient.  Two  varieties  of  muscse — the  transparent  and 
the  opaque  —  are  commonly  met  with,  and  they  occur 
mostly  amongst  myopic  patients  and  those  who  use  their 
e^'es  much  for  fine  or  close  work. 

The  transparent  miiscee  are  best  seen  when  looking  up 
in  the  light,  or  against  a  white  surface  through  a  small 
aperture  in  a  card,  or  with  the  lids  partially  closed.  They 
consist  of  numerous  small  transparent  bead-like  bodies, 
some  of  them  hanging  together  in  rows  or  in  clusters, 
whilst  others  are  floating  as  isolated  circles  in  myriads 
before  the  eye.  They  do  not  obscure  vision,  as  every- 
thing is  seen  clearly  through  them,  or  by  their  side.  If 
the  eyes  are  suddenly  turned  upwards  and  then  fixed, 
the}^  will  be  observed  by  the  patient  to  float  slowly  down- 
wards, as  if  gravitating  to  the  fundus  of  the  glode.  They 
are  perfectly  innocuous,  and  merely  represent  the  corpus- 
cles of  the  vitreous  and  debris  of  cells,  which  in  certain 


144  DISEASES    OF   THE    VITREOUS. 

lights  become  obvious  to  the  eye  in  which  they  exist. 
The  different  shapes  assumed  by  these  transparent  muscse 
are  caused  by  aggregations  of  the  corpuscles  either  into 
groups  or  strings. 

Opaque  Muscee. — The  second  form  of  mote  which  is 
often  complained  of  consists  of  one  or  more  dark  spots  of 
different  fantastic  shapes,  which  are  constantlj'  floating 
before  the  field  of  vision,  and  shifting  with  the  movements 
of  the  eye.  Thej^  will  appear  suddenlv,  and  remain  for 
3-ears  without  increasing  or  diminishing,  or  without  the 
eye  becoming  in  any  other  way  affected.  They  will  also 
disappear  occasionall}'  for  months  or  longer,  and  then 
turn  up  again  in  their  old  familiar  form.  This,  perhaps, 
may  be  explained  by  supposing  that  the  body  of  which 
the  mote  is  composed  floated  out  of,  and  was  for  a  time 
accidentall}^  kept  from,  the  field  of  vision,  when,  again  be- 
coming free,  it  reappeared.  The  cause  of  these  opaque 
muscae  it  is  difficult  to  ascertain.  They  may  be  the  de- 
bris of  cells  congregated  together,  or  opaque  detached 
filaments  from  the  connective  tissue  of  the  vitreous,  or  a 
little  of  the  pigment  of  the  uvea  which  has  been  acci- 
dentally detached  from  the  ciliary  processes  and  worked 
its  way  into  the  vitreous.  Donders,  in  speaking  of  miiscae 
volitantes,  says,  "I  succeeded  in  finding,  on  microscopic 
examination,  with  Professor  Jansen,  some,  and  subse- 
quentl}'  with  Dr.  Doncan,  all  forms  in  the  vitreous  hu- 
mor of  the  human  eye."  He  detected  "  pale  cells  and 
debris  of  cells  in  a  state  of  mucine-metamorphosis  ;  fibres 
furnished  with  granules,  and  groups  of  granules  with  ad- 
herent granular  fibres."  * 

Treatment. — Rest  the  eyes  by  abstaining  from  all  close 
work,  and  avoid  constantl}^  looking  for  the  musc«.     If  in 

*  Bonders  on  the  Accommodation  and  Kefraction  of  the  Eye, 
Sj'denham  Society,  p.  199. 


OPACITIES    OF    THE    VITREOUS.  145 

bright  lights  they  become  visible  without  the  patient 
searching  for  them,  he  should  be  provided  with  neutral 
tint  or  dark  cobalt-blue  glasses.  Tonics  of  quinine  or 
iron  frequently  do  good  by  improving  the  health  and  ren- 
dering the  eye  and  the  mind  of  the  sufi'erer  less  impres- 
sionable to  little  defects.  No  local  applications  will  be 
of  any  service  for  the  getting  rid  of  the  true  muscae  voli- 
tantes.  The  patient  should  be  assured  that  they  are  not 
portentous  of  coming  blindness,  and  that  they  may  con- 
tinue for  years  without  causing  an}-  more  than  their  pres- 
ent annoyance.  Muaese  must  not  be  confounded  with 
scotomata,  which  are  fixed  blind  spots  in  the  field  of  vision, 
dependent  on  a  complete  loss  of  sensibility  of  a  portion 
of  the  retina. 

Opacities  or  the  Yitreous  are  a  frequent  result  of 
disease  of  the  iris,  choroid,  and  retina,  and  especially  of 
those  affections  which  have  a  syphilitic  origin.  They  may 
be  due  to  inflammatory  changes  in  the  cells  or  connective 
tissue  of  the  vitreous,  or  to  small  effusions  of  lymph,  or 
to  extravasations  of  blood.  They  are  frequently  asso- 
ciated with  a  general  turbidity  of  the  vitreous,  but  they 
ma}^  also  exist  in  large  numbers  when  that  structure  is 
perfectl}^  transparent,  so  that  with  the  aid  of  the  ophthal- 
moscopic mirror  these  opaque  bodies  may  be  seen  floating 
in  a  perfectly  clear  medium.  The  opacities  may  assume 
a  variety  of  forms  resembling  either  grains  of  soot,  dark 
threads,  or  membranous  expansions.  When  they  are 
numerous,  there  is  usually  great  impairment  of  vision  ; 
but  this  is  often  as  much  due  to  the  disease  which  has  led 
to  their  formation  as  to  the  impediment  they  offer  to  the 
passage  of  light  to  the  retina.  Those  which  are  placed 
deeply  in  the  vitreous  create  the  most  confusion  by  throw- 
ing their  shadows  on  to  the  retina. 

Treatment. — Opacities  of  the  vitreous  must  be  treated 
13 


146  DISEASES    OF   THE   VITREOUS. 

by  attacking  the  disease  which  has  given  rise  to  them. 
Those  which  have  a  syphilitic  origin,  and  are  dependent 
on  small  plastic  effusions,  are  more  amenable  to  remedies 
than  any  of  the  other  forms.  For  the  filni}^  opacities  due 
to  hemorrhage  nothing  can  be  done.  In  the  course  of 
time  they  will  shrink  considerably,  and  many  of  them  will 
disappear  from  the  field  of  vision.  The  dense  mem- 
branous opacities,  which  greatly  obstruct  vision  by  float- 
ing in  front  of  the  object.  Von  Graefe  has  treated  success- 
fully by  dividing  with  a  fine  needle,  as  in  a  capsular  ope- 
ration after  cataract. 

Sparkling  Synchysis. — Synchysis  scintillans. — These 
euphonious  titles  have  been  given  to  the  beautiful  appear- 
ance which  is  presented  by  sparkling  flakes  of  cholesterine 
floating  in  a  fluid  vitreous.  They  frequently  abound  in 
such  quantities,  that  they  may  be  seen  to  descend  in  a 
perfect  shower  after  every  movement  of  the  eye.  With 
the  ophthalmoscope  the  crystals  of  cholesterine  look  like 
chips  of  gold  leaf,  and  make  the  vitreous  closely  resemble 
the  liqueur  called  gold-water.  The  cholesterine  is  prob- 
ably derived  from  blood  which  at  some  distant  period  had 
been  efl"used  into  the  vitreous. 

Fluidity  of  the  Vitreous — Sy7ichysis — is  the  begin- 
ning of  the  end  of  many  of  the  diseases  of  the  eye  which 
lead  to  blindness.  It  may  be  due  to  ophthalmitis,  or  to 
inflammation  of  the  iris,  choroid,  or  retina.  It  is  one  of 
the  terminations  of  sympathetic  ophthalmia,  and  is  a  fre- 
quent result  of  injuries  of  the  eye  accompanied  with  deep 
or  posterior  intraocidar  hemorrhage.  It  also  usually  oc- 
curs in  hydrophthalmos,  and  in  most  cases  of  general 
staphylomatous  enlargement  of  the  globe.  In  many  dis- 
eases, fluidity  of  the  vitreous  with  softening  of  the  eye 
follows  increased  tension ;  it  is  so  in  sympathetic  ophthal- 


FOREIGN    BODIES    IN   THE   VITREOUS.  147 

mia,  and  in  iridoclioroiditis,  and  frequently  also  in  glau- 
coma. It  then  indicates  that  the  disease  has  done  its 
worst,  and  atrophy  of  the  tissues  within  the  eye  has  com- 
menced. A  fluid  vitreous  does  not  necessarily  imply  a 
soft  eye ;  the  globe  may  in  certain  cases  be  of  its  normal 
tension,  or  it  may  be  even  glaucomatous  and  have  its 
hardness  increased.  A  soft  eye,  however,  usually  indi- 
cates a  fluid  vitreous,  unless  the  diminution  of  tension 
has  been  caused  by  a  recent  escape  of  vitreous  from  an 
injury.  Although  a  loss  of  consistence  of  the  vitreous  is 
commonl}'  produced  b}'  some  inflammatory  disease,  ^et  it 
may  occur  in  e3es  which  have  never  suffered  from  any  in- 
flammatory affection  and  which  still  retain  very  fair  sight. 
Such  eyes,  however,  are  prone  to  the  early  formation  of 
cataract,  and  to  detachment  of  the  retina.  This  fluid 
state  of  the  vitreous  is  frequently  met  with  in  extreme 
myopia  associated  with  large  posterior  staphyloma,  and  in 
cases  of  cataract  coming  on  in  young  people  without  any 
assignable  cause,  but  probabl}'  due  to  defective  nutrition 
arising  from  some  constitutional  ailment. 

A  loss  of  vitreous  occasioned  by  some  penetrating 
wound  is  rapidly  replaced  by  aqueous.  Fresh  vitreous 
is  never  generated.  If  the  amount  lost  be  small,  no  ill 
effects  may  follow,  as  sufficient  aqueous  will  be  kept 
secreted  to  supply  its  place  ;  but  if  the  escape  of  vitreous 
be  large,  the  eye  usually  suffers.  For  a  while  the  globe 
is  plumped  out  by  aqueous,  but  the  supply  after  a  time 
fails  to  meet  the  demand,  and  the  eye  first  becomes  soft, 
then  shrinks,  and  ultimately  all  sight  vanishes. 

Foreign  Bodies  in  the  Yitreous. — A  foreign  body 
may  be  lodged  in  the  vitreous  and  remain  there  for  a  long 
period  provided  it  does  not  exert  anj^  injurious  pressure 
on  any  of  the  other  parts  within  the  eye.  The  danger 
is,  that  with  the  motions  of  the  globe  its  position  may  be 


148  DISEASES    OF    THE    VITREOUS. 

shifted,  and  falling  to  the  fundus  ma}'  then  excite  a 
dangerous  inflaniination,  which  may  lead  to  destruction 
of  the  other  eye  from  sympathetic  ophthalmia. 

Treatment. — If  the  foreign  body  can  be  seen,  an  en- 
deaA'or  should  be  made  to  remove  it. 

Hemorrhage  into  the  Vitreous  may  take  place — 
1.  From  rupture  of  some  of  the  vessels  of  the  ciliary  pro- 
cesses ;  2.  From  choroidal  hemorrhage ;  the  blood  break- 
ing through  the  retina  and  becoming  extravasated  into 
the  vitreous ;  or,  3,  it  may  ensue  from  the  rupture  of  a 
retinal  vessel,  but  this  is  rare. 

Blood  effused  into  the  vitreous  is  but  slowly  absorbed. 
If  the  clot  be  small,  it  gradually  loses  its  coloring  matter, 
and  shrinks,  and  after  a  few  weeks  or  months,  it  is  seen 
with  the  ophthalmoscoi^e  either  as  a  small  dark  mass,  or 
as  floating  filaments  in  the  vitreous.  If,  however,  there 
has  been  much  hemorrhage,  loss  of  the  eye  is  certain  to 
follow.  To  allow  the  blood  to  be  extravasated,  the  h^-a- 
loid  has  to  be  ruptured,  and  wherever  the  blood  forces 
its  way,  it  breaks  down  the  texture  of  the  vitreous.  From 
this  mutilation  of  structure  the  vitreous  does  not  recoA-er  ; 
it  atrophies,  loses  its  consistence,  and  becomes  fluid. 
The  blood-clot  softens  and  is  gradually  dissolved,  and 
its  coloring  matter  stains  the  whole  of  the  fluid  which 
occupies  the  vitreous  space  to  a  yellow  or  brownish-yellow 
tinge,  which  color  may  last  for  years.  The  mischief, 
howcA'er,  does  not  end  here ;  for,  as  the  vitreous  becomes 
fluid,  it  diminishes  in  bulk ;  and  the  retina,  losing  the 
support  which  it  had  received  from  the  healthy  vitreous, 
falls  forward  and  becomes  detached. 


CATARACT.  149 


CHAPTER  IV. 

DISEASES    OF    THE    CRYSTALLINE    LENS. 

Cataract  is  an  opacity  of  the  lens.  In  the  great  ma- 
jority of  cases  the  opacity  is  confined  to  the  lens  sub- 
stance, the  capsule  remaining  transparent. 

Cajjsidar  Cataract  is  the  term  used  when  the  opacity 
is  apparently  limited  to  the  lens  capsule. 

Capsulo-lenticular  Cataract  is  when  there  is  opacity  of 
both  the  lens  and  its  capsule. 

Causes  op  Cataract. — Whatever  interferes  with  the 
due  nutrition  of  the  lens  tends  to  produce  cataract. 

a.  It  may  occiir  from  old  age ;  it  is  then  one  of  the  re- 
sults of  senile  decay,  and  has  been  rightly  called  "senile 
cataract." 

/?.  It  may  be  dependent  on  a  constitutional  disease,  in 
which  the  general  nutrition  of  the  body  fails,  as  in  dia- 
betes.    This  form  is  recognized  as  a  "  diabetic  cataract." 

y.  It  may  be  due  to  disease  of  the  deep  structures  of 
the  eye,  the  choroid  and  retina,  to  which  it  is  indeed 
secondary.  This  class  is  distinguished  as  "  secondary 
cataract." 

S.  It  may  be  produced  by  injury,  and  it  is  then  termed 
"traumatic  cataract." 

e.  Lastly,  it  may  be  congenital. 

Cataracts  may  be  divided  primarily  into  two  great 
classes — soft  and  hard  cataracts. 

I.  SoET  Cataracts  may  occur  at  any  period  between 
infancy  and  thirty  or  thirty-five  years  of  age.     They  may 

13* 


150  DISEASES   OF   THE    CRYSTALLINE    LENS. 

be  congenital,  or  the}^  may  be  dependent  on  one  or  other 
of  the  causes  already' related ;  the  consistence  of  the  cata- 
ract being  mainly  determined  b}^  the  age  of  the  patient. 

Congenital  or  Infantile  Cataract  may  come  on  in 
early  infancy,  or  as  its  name  implies,  it  maybe  a  congeni- 
tal defect.  E^^es  with  this  form  of  cataract  are  usually 
below  the  normal  standard  in  size.  They  are  also  often 
associated  with  other  congenital  deficiencies,  such  as 
microphthalmos  or  small  ill-developed  eyes ;  or  with  a 
stunted  bodil}^  growth ;  or  occasionallj'  with  mental  im- 
pairments, varying  from  slight  imbecility  to  idiotcy.  On 
the  other  hand,  it  is  only  right  to  say  that  I  have  seen 
congenital  cataracts  in  well-grown  and  finely  developed 
patients,  with  a  mental  activity  to  be  admired,  and  with 
such  an  exaltation  of  one  or  other  faculty  as  justly  to 
entitle  them  to  the  rank  of  genius.  Mr.  Bowman  has 
drawn  attention  to  the  fact,  that  there  is  probably  some 
intimate  connection  between  infantile  convulsions  and 
congenital  cataract.  I  have  myself  questioned  the  parents 
of  many  children  who  have  been  aflflicted  with  cataract, 
and  have  been  struck  with  the  number  of  them  who  have 
also  suffered  from  convulsions. 

There  are  two  kinds  of  congenital  cataract,  each  of 
which  requires  to  be  specially  noticed — the  "lamellar," 
and  the  "cortical." 

The  Lamellar  Cataract  is  where  there  is  a  central 
opacity  of  the  lens  with  a  more  or  less  clear  circumferen- 
tial margin.  The  density  of  the  opacity  is  uniform,  and 
seems  to  be  due  to  a  layer  of  opaque  matter  between  the 
central  nucleus  and  the  transparent  surface  of  the  lens. 

The  Cortical  Cataract  is  where  the  opacity  commences 
in  the  margin  of  the  lens,  and  it  is  seen  as  opaque  striae 
running  from  its  circumference  towards  its  centre.  In 
the  early  stage  ol  this  form  of  cataract  the  intermediate 


INVOLUNTARY    OSCILLATIONS    OF    THE    GLOBE.       151 

spaces  are  clear,  and  through  them  the  fundus  of  the  eye 
can  be  exaniined  with  the  ophthahiioscope ;  but  patches 
of  cloudiness  or  opaque  dots  soon  appear  in  different 
parts  of  the  lens,  and  these  gradually  diffuse  themselves 
and  ultimately  render  the  Avhole  opaque. 

The  defect  of  sight  in  congenital  cataract  is  very  vari- 
able ;  it  is  of  course  dependent  on  the  extent  and  density 
of  the  opacity.  A  slight  and  partial  opacity  may  remain 
stationarj'  for  man}-  3'ears,  but  as  a  rule  the  whole  lens 
will,  sooner  or  later,  become  opaque. 

Involuntary  Oscillations  of  the  Globe — Nystag- 
mus— are  frequently  associated  with  congenital  cataract. 
These  movements  are  quite  beyond  the  patient's  control, 
and  continue  without  his  knowledge.  They  generally  in- 
dicate a  somewhat  unsound  state  of  the  nervous  sj-stem 
of  the  eye,  and  they  may  be  either  congenital,  or  brought 
on  from  defective  vision  produced  by  any  cause  during 
childhood.  The  division  of  the  ocular  muscles  affords  no 
relief  to  the  constant  oscillatory  motions. 

In  one  patient,  from  whom  I  had  occasion  to  remove  a 
shrunken  globe  which  oscillated  in  concert  with  its  fellow, 
the  muscles  continued  their  alternating  action,  and  jerked 
the  conjunctiva  to  which  their  cut  ends  had  become  at- 
tached, in  unison  with  the  movements  of  the  remaining 
63^6.  The  onl}'  treatment  which  is  likel}^  to  diminish  the 
frequency  of  the  oscillations  is  to  improve,  if  possible, 
the  sight,  and  this  is  one  of  the  strongest  reasons  in  favor 
of  an  early  operation  for  congenital  cataract  in  those  cases 
where  the  opacity  of  the  lens  is  sufficient  to  prevent  the 
child  discerning  objects.  When  the  cataract  is  thus  com- 
plete, even  though  there  ma}'  be  no  oscillator}-  movements, 
they  may  after  a  time  be  acquired,  and  the  good  effects 
of  a  future  operation  will  be  then  diminished. 

Ti^eatment  of  Congenital  Cataract. — In  those  cases  in 


V 

152  DISEASES    OF   THE    CRYSTALLINE   LENS. 

■which  the  opacity  is  central,  and  the  margin  of  the  lens 
clear,  and  where  there  is  reason  to  hope  that  the  cataract 
is  not  progressive,  Mr.  Critchett  has  adopted  his  opera- 
tion of  iridodesis.  By  drawing  the  pupil  opposite  to  that 
portion  of  the  lens  which  is  transparent,  good  sight  is 
often  at  once  secured  to  the  patient.  The  advantages 
which  this  operation  offers  are,  that  its  object  is  attained 
quickly,  and  with  even  less  risk  than  that  which  accom- 
panies the  removal  of  the  lens  by  solution ;  and,  secondl}', 
the  patient  seeing  through  the  margin  of  his  own  lens,  is 
able  to  use  his  ej'es  without  the  aid  of  cataract  glasses. 

The  disadvantages  of  this  operation  are,  however,  great, 
as  congenital  cataract  is  very  rarely  stationary,  but  sooner 
or  later  the  opacity  extends,  and  a  farther  operation  is 
then  required.  When  this  becomes  necessary,  the  eye  is 
in  a  much  less  favorable  condition  for  any  operative  pro- 
cedure, and  the  results  will  not  be  so  satisfactory. 

The  operations  which  are  suited  for  congenital  or  other 
forms  of  soft  cataract  are — 

1.  Solution  and  absorption  of  the  lens. 

2.  Linear  extraction. 

3.  The  suction  operation. 

Operation  by  Solltion  —  Keratonyxis  —  consists  in 
breaking  up  with  a  flue  needle  the  central  portion  of  the 
capsule  of  the  lens,  so  as  to  freely  admit  the  aqueous,  and 
allow  it  to  exert  its  solvent  influence  on  the  lenticular 
matter.  A  description  of  this  operation  is  given  at  page 
153,  under  the  heading  of  "  the  first  stage  of  the  operation 
of  linear  extraction,"  the  only  diflerence  being  that  the 
lens  substance  should  not  be  quite  so  freely  comminuted. 
The  precautions  which  are  there  given,  both  prior  to  and 
after  the  operation,  with  reference  to  the  dilatation  of  the 
pupil,  must  be  rigidly  followed.  Occasionally  one  needle 
operation  will  suffice,  but  generally  it  has  to  be  repeated 


EXTRACTION  OF  CATARACT.  153 

two  or  three  times  before  the  whole  of  the  lens  is  absorbed. 
The  intervals  between  each  operation  mnst  be  regulated 
by  the  progress  of  the  case ;  from  three  to  six  months  is 
the  time  which  is  nsnally  required.  If  after  one  of  the 
needle  operations  the  swollen  lens  should  press  injuri- 
ously on  the  iris,  and  produce  symptoms  of  irritation, 
the  second  stage  of  linear  or  suction  extraction,  page 
155,  should  be  at  once  performed,  and  the  lens,  or  what 
remains  of  it,  be  removed. 

This  method  of  dealing  Avith  a  congenital  or  soft  cata- 
ract is  undoubtedly  the  safest  of  all  the  operations,  and 
I  believe  the  results  on  the  whole  are  the  most  satisfac- 
tory. It  presents,  however,  these  difficulties :  the  process 
of  the  absorption  of  the  opaque  lens  occupies  a  long 
period,  and  it  is  essential  for  the  safety  of  the  eye  that 
the  patient  should  continue  during  that  time  under  the 
supervision  of  the  surgeon. 

Linear  Extraction  of    Cataract The  operation 

known  as  Gibson's,  from  the  late  Mr,  Gibson,  of  Man- 
chester, having  first  suggested  and  performed  it,  is  now 
recognized  and  practised  with  some  slight  modifications, 
under  the  name  of  linear  extraction. 

It  is  well  adapted  to  a  large  majority'  of  the  cases  of 
soft  cataract,  but  it  is  an  operation  which  requires  great 
care,  and  great  delicacy  of  manipulation. 

Prior  to  performing  the  operation,  the  pupil  should  be 
fully  dilated  with  atropine,  so  that  the  whole  of  the  lens 
may  be  under  the  observation  of  the  operator,  and  the 
iris  ma}'  be  drawn  away  as  far  as  possible  from  the  chance 
of  injury. 

The  operation  ma}'  be  divided  into  two  stages. 

The  first  stage  of  the  operation  is  to  break  up  with  a  fine 
needle  (Fig.  8)  two-thirds  of  the  anterior  capsule  of  the 
lens ;  and  by  carefully  moving  the  needle  through  the  soft 


154  DISEASES    OF   THE   CRYSTALLINE   LENS. 

lenticular  matter,  so  as  to  comminute  it,  that  every  portion 
of  it  may  be  brought  into  contact  with  the  aqueous. 
Fig.  8.  Great  care  must  be  taken  not  to  injure  the  pos- 
terior la3^er  of  the  capsule  of  the  lens,  as  by  so 
doing  the  h^'aloid  membrane  would  be  ruptured, 
and  the  vitreous  mixing  with  the  particles  of  the 
lens  would  materially  interfere  with  the  due  action 
of  the  aqueous  humor  on  them,  and  also  render 
more  difficult  the  second  part  of  the  operation. 

After  the  operation,  the  patient  should  be  kept 
in  a  darkened  room,  but  not  in  bed,  and  a  solu- 
tion of  atropine  of  the  strength  of  gr.  2  ad  aquse  ^   1, 
should  be  dropped  into  the  eye  twice  a  day. 

The  second  stage  of  linear  extraction  consists  in  remov- 
ing the  broken-down  lens  through  a  small  linear  opening 
in  the  cornea.  Before  it  is  attempted,  if  nothing  has 
happened  since  the  first  operation  to  necessitate  its  im- 
mediate performance,  sufficient  time  should  be  allowed 
to  elapse  for  all  the  transparent  portions  of  the  lens  to 
become  opaque,  and  somewhat  macerated  b}'  the  aqueous. 
From  three  to  six  daj-s  will  be  about  the  time  required 
for  the  desired  changes  to  take  place,  but  much  depends 
on  the  condition  of  the  cataract  at  the  time  of  the 
Fig.  9.  operation,  and  upon  the  extent  to  which  the  cap- 
I  sule  has  been  torn,  and  the  lenticular  matter 
broken  up. 

The  pupil  being  widely  dilated  with  atropine,  an 
opening  is  to  be  made  in  the  cornea  with  a  broad 
needle  (Fig.  9)  at  a  point  just  external  to  where  the 
pupillary  margin  of  the  iris  is  seen.  Instead  of 
inserting  the  needle  through  the  cornea  directly 
from  before  backwards,  it  should,  as  Mr.  Bowman 
has  suggested,  be  made  to  pass  obliquely-  inwards 
through  the  lamellae  of  the  cornea.  The  aperture 
thus  made  will  be  valve-shaped,  the  object  being,  that  the 


OPERATIONS  FOR  CATARACT. 


155 


curette  in  and  after  its  introduction  shall  not  press  at  all 
upon  the  iris. 

A  sufficient  opening  having  been  made,  the  curette, 
Fig.  10,  is  next  to  be  introduced,  and  this  should  be  done 
with  a  gentle  lateral  motion.     The  eye  being  still  held  by 
the  surgeon  with  a  pair  of  forceps  in  the  most 
convenient  position,   the  curette  is  moved       Yiq.  10. 
gently  from  side  to  side,  pressing  slightly 
on  the  mouth  of  the  wound  to  permit  the 
aqueous  with  the  softened  lens  to  flow  down 
its  groove.    When  the  largest  portion  of  the 
lenticular  matter  has  escaped,  small  opaque 
pieces  will  occasionally  be  seen  which  have 
not  flowed  away  in  the  stream ;  these  may 
be  followed  by  the  curette,  and  on  the  point 
of  it  being  dipped  beneath  them,  thej^  will 
also  escape  along  its  groove.     All  the  move- 
ments of  the  curette  must  be  conducted  with 
the  greatest  caution,  as  it  is  essential  that 
the  posterior  capsule  should  not  be  broken.     When  this 
accident  happens,  the  opaque  fragments  of  lens  become 
entangled  in  the  vitreous,  and  no  further  attempt  should 
be  made  to  remove  them. 

The  lens  having  been  removed,  or  as  much  of  it  as  will 
readily  flow  away,  the  patient  is  to  be  sent  to  bed  in  a 
darkened  room,  and  the  pupil  is  to  be  kept  under  the  in- 
fluence of  atropine. 


Extraction  of  Soft  Cataract  by  Suction. — This 
method  of  removing  a  soft  cataract  was  reintroduced  by 
Mr.  T.  Pridgin  Teale,  Jr.,  of  Leeds,  who  suggested  the 
operation,  and  performed  it  with  success  in  December, 
1863,  on  a  j^oung  man  who  had  a  traumatic  cataract. 

The  extraction  of  the  lens  by  suction  may  be  completed 
in  one  operation,  but  my  own  feeling  is  that  it  is  better. 


156  DISEASES    OF   THE    CRYSTALLINE    LENS. 

as  a  vule,  to  divide  it  into  two  stages.  The  fimt  Mage  is 
tlie  same  as  the  preliminary  needle  operation  for  linear 
extraction  described  at  page  153.  Two,  three,  or  four 
days  having  elapsed,  the  second  stage  or  suction  part  of 
the  operation  ma}-  be  performed,  and  the  whole  lens,  now 
opaque  and  diffluent,  will  be  readily  drawn  through  the 
tubular  curette  of  the  instrument. 

The  second  stage ^  or  the  suction  part  of  the  operation^ 
ma}'  be  performed  as  follows  :  The  pupil  having  been  pre- 
viously^ fiiily  dilated  with  atropine,  an  opening  is  made 
in  the  cornea  with  a  broad  needle,  immediately^  within 
the  pupillar}'  margin  of  the  dilated  pupil,  sufficient  in 
size  to  allow  of  the  easy  entrance  of  the  tubular  curette. 
A  delicate  manipulation  of  the  instrument  is  required  to 
move  it  from  point  to  point,  so  as  to  place  the  open 
month  of  the  curette  in  the  most  favorable  positions  for 
sucking  in  the  lens  matter,  without  in  any  waj^  injuring 
the  iris.  The  suction  power  must  be  carefully  regulated 
b}^  the  operator,  who  is  able  to  arrest  it  instantl}'  if  neces- 
sary. 

The  best  suction  instrument  is  that  made  b}'  Messrs. 
AYeiss  of  the  Strand.  The  suction  power  is  obtained 
through  a  delicate  metal  sj^ringe  placed  at  one  extremity 
of  a  glass  tube,  which  is  furnished  at  the  other  end  with 
a  tubular  curette,  the  aperture  of  which  is  countersunk. 
The  syringe  is  so  contrived,  that  with  one  hand  the  piston 
can  be  worked,  and  the  movements  of  the  curette  within 
the  eye  guided,  whilst  the  other  hand  is  left  free  to  fix 
the  globe  with  a  pair  of  forceps. 

II.  Hard  Cataracts  are  characterized  b}'  a  firm  nu- 
cleus, and  ma}'  occur  at  any  period  of  life  after  35  or  40 
years  of  age.  There  are  ditterent  forms  of  hard  cataract, 
which  are  distinguished  from  each  other:  1,  by  the  part 


CATARACT.  157 

of  the  lens  in  which  the  opacit}'  begins  ;  2,  by  its  general 
appearance;  and  3,  by  the  age  of  the  patient. 

Nuclear-  Cataracts  are  those  in  which  the  opacity  com- 
mences in  the  nucleus,  the  marginal  portion  of  the  lens 
remaining  for  a  time  transparent. 

Striated  Catai-acts. — The  opacit}^  first  shows  itself  in 
opaque  lines  in  the  cortical  substance  of  either  the  ante- 
rior or  posterior  surface  of  the  lens,  or  in  some  cases  in 
both  simultaneously.  These  strife  radiate  from  the  cir- 
cumference towards  the  centre  of  the  lens. 

Black  Cataracts. — There  are  two  classes  of  cataract  to 
which  the  name  black  has  been  given.  1st.  To  the  hard 
opaque  senile  lenses,  in  which  the  nucleus  has  acquired 
an  exceptionally  dark  reddish-brown  color.  2d.  To  those 
rare  cases  in  which  a  lens  with  commencing  cataract  has 
become  darkl^"^  stained  with  haematine  from  some  prior 
extravasation  of  blood  into  the  aqueous  chamber.  Dis- 
solved in  the  aqueous,  the  haematine  has  permeated  the 
lens  capsule  and  been  deposited  in  the  lens  substance. 

Senile  Cataracts  usually  occur  from  50  to  55  years  of 
age.  They  may  be  either  nuclear  or  striated.  They  vary 
greatly  in  consistence,  but  are  always  distinguished  by 
the  presence  of  a  distinct  firm  nucleus.  In  some  cases 
the  nucleus  is  small  and  hard,  with  a  good  deal  of  soft 
cortical  matter  surrounding  it ;  in  other  patients  the  nu- 
cleus is  large,  hard,  and  amber-colored,  and  with  scarcely 
a  trace  of  cortical  substance.  Lastly  there  is  a  third  class 
of  senile  cataracts,  in  which  there  is  a  small  or  medium- 
sized  nucleus,  surrounded  by  an  opaque  but  fluid  cortex. 

The  P7'ogress  of  Hard  Cataracts  is  ver}'  variable.  In 
one  patient  its  formation  will  be  ver}^  rapid,  whilst  in 
another  it  will  take  man}'  years  before  the  whole  lens  be- 
comes opaque.  Again,  it  may  be  slow  in  its  early  stages, 
but  develop  itself  quickty  in  the  last. 

Treatment  of  Hard  Cataracts As  a  rule  it  is  wise  to 

14 


158  DISEASES    OF   THE    CRYSTALLINE   LENS. 

postpone  an  operation  for  the  extraction  of  a  bard  cata- 
ract until  the  whole  lens  is  opaque.  This  may  be  always 
couvenientl}'  done  when  one  eye  only  is  affected ;  but  it 
often  happens  that  the  cataract  is  slowly  advancing  in 
both  e3'es,  and  the  sight  has  become  so  far  dimmed  as  to 
prevent  the  patient  following  the  business  on  which  his 
daily  bread  depends.  In  such  a  case  the  patient  cannot 
afford  to  wait,  and  one  of  two  courses  may  be  pursued. 

1.  The  lens  ma}'  be  extracted  from  one  eye  b}'  a  "modi- 
fied linear  extraction  operation."  If  some  soft  cortical 
matter  remains  behind,  the  pupil  must  be  kept  dilated 
with  atropine  after  the  section  has  united. 

2.  Before  attempting  any  operation  the  surgeon  may 
prick  the  lens  with  a  fine  needle,  simpl}^  puncturing  its 
capsule  at  two  or  three  points,  so  as  to  admit  sufficient 
aqueous  to  render  opaque  the  transparent  portions  of  the 
lens.  The  patient  should  then  be  placed  for  a  few  da3's 
in  a  darkened  room,  and  the  pupil  kept  under  the  influ- 
ence of  atropine,  so  as  to  ward  off"  any  of  the  inflamma- 
tory eff'ects  which  pricking  a  hard  lens  will  sometimes 
produce.  When  all  irritation  has  subsided,  the  opaque 
lens  may  be  extracted  by  the  operation  the  surgeon  may 
select. 

When  both  eyes  are  affected  with  cataract,  the  two 
operations  should  never  be  performed  at  the  same  time. 
The  risk  is  too  great.  Some  accidental  cause,  which,  on 
a  future  occasion,  miglit  be  averted,  may  influence  the 
patient  unfavorabh',  and  both  e3'es  ma}'^  be  lost.  No 
operation  should  be  done  on  the  second  eye  until  the  re- 
sult of  the  first  has  been  decided. 

For  the  extraction  of  a  hard  cataract,  one  of  the  follow- 
ing operations  may  be  selected. 

Flap   Extraction   Operation  for   Cataract The 

principle  of  this  operation  is  to  make  a  section  of  the 


OPERATIONS  FOR  CATARACT. 


159 


Fig.  11. 


cornea  of  such  a  size  as  will  admit  of  the  easy  exit  of  the 
lens.  The  incision  should  be  confined  throughout  its 
extent  to  the  true  corneal  tissue.  The  patient  should  lie 
on  a  couch  with  his  head  slightl}^  raised,  and  the  operator 
should  stand  behind.  If  he  is  ambidextrous,  the  knife 
should  be  held  in  his  right  hand  for  the  right  eye,  and  in 
his  left  for  the  left  63*6 ;  but  if  he  is  unable  to  work  with 
his  left  hand,  he  must  stand  in  front  of  the  patient  and 
make  the  corneal  incision  in  the  left  eye  with  his  right 
hand. 

Ojicration — First  step. — The  upper  lid  is  to  be  raised 
by  the  index  finger  of  the  operator,  and  maintained  in 
this  position  by  its  tarsal  margin  being  pressed 
slighth^  against  the  edge  of  the  orbit,  whilst  his 
middle  finger  is  placed  against  the  sclerotic  on 
the  inner  side  of  the  globe,  to  prevent  its  roll- 
ing inwards  before  the  point  of  the  knife  has 
transfixed  the  cornea.  The  lower  lid  is  to  be 
drawn  down  by  one  finger  of  the  assistant,  with 
which  he  presses  it  against  the  malar  bone,  so 
as  to  avoid  making  any  pressure  on  the  eye. 
The  point  of  a  Beer's  or  Sichel's  knife  (Fig.  11), 
with  its  edge  upwards,  is  now  made  to  enter  the 
cornea,  just  within  the  corneal  margin,  and  at 
about  the  level  of  the  centre  of  the  pupil.  The 
blade  is  then  urged  steadily  onwards  across  the 
anterior  chamber  in  front  of  the  iris,  until  its 
point  transfixes  the  cornea  at  a  spot  correspond- 
ing to  that  at  which  it  entered.  The  section  is  to  be  com- 
pleted slowly  in  the  withdrawal  of  the  knife,  the  edge  of 
which  is  to  be  directed  slightly  forwards  as  it  cuts  its  waj'' 
out.  A  too  rapid  completion  of  the  incision  is  apt  to  be 
followed  by  a  spasmodic  contraction  of  the  muscles  of 
the  e3'e  with  an  escape  of  the  lens,  an'd  very  probably'  of 
a  part  of  the  vitreous  also. 


160 


DISEASES    OF    THE    CRYSTALLINE    LENS. 


When  there  is  much  spasm  of  the  ocular  muscles  or 
straining  on  the  part  of  the  patient,  it  is  often  wise  to 
draw  out  the  knife  before  quite  finishing  the  section,  and 
thus  leave  a  small  bridge  of  cornea  to  be  cut  through  with 
a  small  secondarj^  knife  (Fig.  12j,  after  the  capsule  has 
been  opened. 

The  second  step  of  the  operation  is  to  tear  through  the 
anterior  capsule  of  the  lens.  The  patient  is  told  to  look 
downwards  at  his  hands  or  his  feet,  so  as  to  expose  fuU^' 
the  corneal  wound,  thi'ough  which  the  ordinary  pricker, 
or  Graefe's  c3-stotome  (Figs.  13,  14),  is  then  introduced 
sidewa3-s,  and  the  capsule  freely  opened. 


Fig.  12. 


Fig.  13. 


Fig.  14. 


Tl\e  third  stej:)  is  the  evacuation  of  the  lens  through  the 
corneal  section.  The  patient  is  again  directed  to  look 
towards  his  feet,  when  the  operator  jDlaces  the  point  of 
his  finger  on  the  upper  eyelid,  and  presses  gently'  on  the 
globe,  whilst  he  applies  the  side  of  the  curette  (Fig.  10) 
along  the  lower  lid,  through  which  he  exerts  a  steady 
pressure  on  the  eye,  which,  if  necessary,  is  so  regulated 
as  to  alternate  with  that  being  made  by  the  finger  above. 
As  the  lens  begins  to  escape  through  the  wound,  the 


OPERATIONS   FOR    CATARACT.  161 

pressure  on  the  globe  must  be  relaxed  ;  and  in  many  cases 
just  before  its  expulsion  is  completed,  it  must  be  entirely 
removed,  as  the  too  rapid  exit  of  the  lens  is  often  accom- 
panied by  an  escape  of  vitreous. 

Accidents  which  may  happen  in  the  course  of  the 
Operation.— a.  The  aqueous  may  escape  too  soon,  so 
that  the  iris  may  fall  in  front  of  the  knife.  When  this 
happens,  the  operator  should  press  the  cornea  gently 
against  the  blade  with  one  of  his  fingers,  whilst  at  the 
same  time  he  continues  the  section  with  the  edge  of  the 
knife  turned  slightlj^  forwards.  By  this  manoeuvre  the 
iris  will  often  be  made  to  recede,  and  the  section  be  com- 
pleted without  cutting  it. 

/3.  The  section  may  be  too  small.  When  this'  is  the 
case,  the  incision  should  be  enlarged  with  a  secondary 
knife. 

y.  The  vitreous  may  escape  before  the  lens.  This  may 
be  caused  by  the  incision  being  cai'ried  into  the  sclerotic, 
or  from  the  straining  and  struggling  of  the  patient. 
When  this  casualt3^  occurs,  all  pressure  on  the  eye  should 
be  at  once  released,  and  the  lens  should  be  withdrawn 
from  the  eye,  if  possible,  in  its  capsule  by  one  of  the 
spoons  (Figs.  15,  23)  used  in  the  traction  operation  for 
cataract. 

8.  Deep  intraocular  hemorrhage  may  occur.  This  is 
the  most  fatal  accident  which  can  happen ;  the  eye  is 
always  irrecoverably  lost.  It  most  frequently  happens  in 
eyes  which  are  glaucomatous,  or  otherwise  previously  dis- 
eased. The  bleeding  usually  takes  place  from  between 
the  choroid  and  sclerotic.  See  article  Hemorrhage  be- 
tween Choroid  and  Sclerotic 

Remarks  on  Flap  Extraction'  of  Cataract. — The 
cases  which  seem  to  me  most  fitted  for  the  flap  operation 

14* 


162  DISEASES    OF   THE   CRYSTALLINE    LENS. 

are  senile  cataracts  in  thin  wiry  patients,  who  have  rather 
deep-set  eyes,  and  possess  good  control  over  their  emo- 
tions. The  operation  is  usually  attended  with  a  little 
difficulty  if  the  eyes  are  much  sunken,  but  the  results  I 
have  generally  found  good.  When  patients  cannot  or 
will  not  take  chloroform,  the  flap  extraction  should  be 
selected,  if  not  contraindicated  by  some  special  cause,  as 
it  is  not  only  the  least  painful  of  all  the  operations  for 
cataract,  but  it  is  also  the  most  expeditious.  Lastly,  the 
flap  operation  is  quite  inadmissible  in  patients  who  have 
cough,  or  who  are  liable  to  sudden  and  repeated  sneez- 
ings. 

The  Traction  Operation  was  first  suggested  by  Yon 
Graefe  for  those  forms  of  traumatic  cataract  where  the 
niicleus  was  too  dense  to  be  easily  removed  by  linear  ex- 
traction. His  assistant.  Dr.  Schuffc  (now  Waldau),  ex- 
tended the  application  of  this  operation  to  cases  of  ordi- 
nary cataract,  and  designed  a  series  of  scoops  for  the 
drawing  out  of  the  opaque  lens  from  the  eye.  His  de- 
scription of  the  operation  is  published  in  the  Royal  Lon- 
don Ophthalmic  Hospital  Reports,  vol.  iii,  page  159. 

The  object  of  the  operation  is  to  draw  the  opaque  lens 
out  of  the  e3'e  through  a  slit-like  opening,  in  preference 
to  the  large  incision  with  a  corneal  flap.  A  portion  of  the 
iris  is  removed  at  an  early  stage  of  the  operation,  so  as  to 
avoid  contusion  or  laceration  of  its  structure,  from  the  in- 
troduction of  instruments  within  the  eye  for  the  with- 
drawal of  the  lens. 

Tlie  first  stage  of  the  operation  is  to  make  a  sufficient 
opening  in  the  margin  of  the  cornea  for  the  extraction  of 
the  lens,  and  to  remove  a  portion  of  the  iris.  The  ope- 
rator stands  at  the  head  of  his  patient,  and  with  his  left 
hand  fixes  the  eye  with  a  pair  of  forcejjs,  just  below  the 
centre  of  the  lower  margin  of  the  cornea,  at  the  spot  di- 


OPERATIONS  FOR  CATARACT.  168 

rectly  opposite  to  that  where  he  wishes  to  introduce  the 
point  of  his  triangular  knife.  AVitli  the  right  hand  he 
malces  the  incision  into  the  upper  border  of  the  cornea  with 
a  lance-shaped  iridectomy  knife  (Fig.  3,  p.  Ill),  causing 
it  to  enter  that  structure  at  the  corneo-sclerotic  junction. 
The  opening  should  always  be  made  sufficiently  large  to 
allow  of  the  easy  introduction  of  the  scoop,  and  the  ready 
escape  of  the  lens.  If  the  aperture  is  found  on  the  with- 
drawal of  the  knife  not  to  be  ample  enough,  it  should  be 
enlarged  laterally  by  a  pair  of  scissors. 

He  next  proceeds  to  excise  a  i:)ortion  of  the  iris.  This 
he  does  by  introducino-  a  pair  of  iris  forceps  (Fig.  4,  p.  112) 
through  the  wound,  and  seizing  the  iris  near  its  pupillary 
border,  draws  out  a  portion  of  it,  and  cuts  off  as  much  as 
he  desires  with  a  pair  of  fine  scissors.  If  the  iris  has  al- 
ready prolapsed  through  the  corneo-sclerotic  incision,  he 
has  only  to  take  hold  of  it  with  the  iris  forceps,  whilst  he 
removes  a  piece  of  it  with  the  scissors. 

The  second  stage  of  the  opei^ation  is  to  tear  through  the 
capsule  of  the  lens.  This  is  to  be  done  with  an  ordinary 
pricker  (Fig.  13),  or  with  Yon  Graefe's  fleam-cj'stotome 
(Fig.  14),  which  should  be  gentl}'  introduced  sideways 
through  the  section,  so  as  to  avoid  tearing  the  iris  or 
scratching  the  inner  surface  of  the  cornea. 

The  third  stage  of  the  operation  is  the  withdrawal  of  the 
lens  from  the  e^'e.  This  is  accomplished  by  gently  intro- 
ducing the  traction  instrument  through  the  wound,  using 
scarcely  any  perceptible  force,  but  urging  it  onwards  by 
one  or  two  slight  lateral  movements,  directing  it  at  the 
same  time  first  a  little  backwards,  so  as  to  insinuate  its 
extremity  between  the  posterior  surface  of  the  lens  and  its 
capsule,  and  then  downwards  and  slighth'  forwards,  allow- 
ing it  almost  b}'  its  own  weight  to  follow  the  posterior 
curvature  of  the  lens.  Having  secured  the  lens  within 
its  grasp,  the  instrument  is  to  be  gradually  Avithdrawn, 


164 


DISEASES    OF   THE    CRYSTALLINE   LENS. 


slightly  depressing  its  handle  during  this  inoA-ement,  so 
as  to  draw  the  lens  with  it  out  of  the  eye.  If  the  whole 
lens,  as  occasionally  happens,  is  brought  out  with  the  first 
withdrawal  of  the  instrument,  the  operation  is  completed. 
Generall}^,  however,  some  soft  lenticular  matter  is  left 
behind,  and  sometimes  some  fragments  of  the  nucleus 
which  have  become  detached.  A  cataract  spoon  must 
now  be  reintroduced  to  bring  awa}'  the  lens  matter  which 
remains. 

For  the  withdrawal  of  the  lens  from  the  eye  several 
diiferent  shaped  spoons  have  been  devised.  Fig.  15  is  a 
front  view  of  one  used  b}^  Mr.  Critchett.     Figs.  16,  17 


Pig.  15.       Fig.  16.     Fig.  17. 


Fig.  18. 


represent  a  front  and  side  view  of  a  spoon  designed  by 
Mr.  Bowman.  For  the  removal  of  any  soft  lenticular 
matter  which  maj*  remain  after  the  nucleus  of  the  lens  has 
been  taken  awa}',  one  of  Schuft's  (now  Waldau's)  spoons 
(Fig.  18)  will  be  fonnd  verj^  useful. 


Graefe's  Modified  Linear  Extraction  is  the  opei*a- 
tion  which  now  gives  the  most  general  satisfaction  for  the 


OPERATIONS  FOR  CATARACT. 


165 


removal  of  senile  cataracts.  It  is  the  one  which  requires 
the  least  selection  of  cases,  and  fields  the  most  favorable 
results. 

He  has  divided  the  operation  into  five  stages  : 

1.  The  Incixion. — The  lids  should  be  separated  by  a 
stop-speculum,  and  the  globe  steadied  by  a  pair  of  forceps 
in  the  left  hand  of  the  ojjerator,  with 

which  he  takes  hold  of  the  conjunctiva  ^^^-  ^^^ 
and  deep  fascia  at  a  point  just  below  the 
centre  of  the  cornea.  The  point  of  a  fine 
knife  (Fig.  19)  is  then  inserted  at  A,  Fig. 
20,  about  Y"  fi'om  the  margin  of  the  cor- 
nea ;  it  is  first  to  be  directed  towards 
c,  so  as  to  extend  slightly  the  inner 
wound,  and  when  it  has  fairly  entered 
the  anterior  chamber,  it  is  to  be  turned 
upwards  to  b,  where  the  counterpunc- 
ture  is  made.  The  blade  is  now  pushed 
ou  a  little  way  in  the  scleral  plane,  and 
then  being  turned  steeply  forwards,  it 
should  cut  its  way  out.  The  section  should  be  completed 
in  the  withdrawal  of  the  knife.  The  length  of  the  incision 
must  be  proportioned  to  the  size  and  density  of  the  lens. 
A  small  flap  of  conjunctiva  is  generally  made  with  the 
sclerotic  section. 

2.  The  Iridectomy. — The  forceps  are  now  to  be  handed 
to  the  assistant,  who  steadies  the  eye,  and,  if  necessary, 
slightly  rotates  it  downwards,  whilst  the  operator  seizes 
hold  of  the  iris  with  the  iris  forceps,  and  cuts  off"  the  pro- 
truding portion,  taking  care  that  no  ends  of  it  are  left  in 
the  edges  of  the  wound. 

3.  Dilaceration  of  the  Capside. — This  is  to  be  accom- 
plished by  drawing  the  point  of  the  cj'stotome  over  the 
lens  capsule  from  the  lower  edge  of  the  pupil  to  the  upper 


166 


DISEASES    OF   THE   CRYSTALLINE    LENS. 


equator  of  the  lens,  first  along  its  nasal,  then  along  its 
temporal  margin. 

4.  Evacuation  of  the  Lens. — This  is  usually  easily 
effected  by  gently  pressing  and  at  the  same  time  sliding 
upwards  the  curve  of  the  curette  against  the  lower  por- 
tion of  the  cornea,  whilst  the  fixing  forceps  are  made  to 
pull  on  the  eye  slightly  downwards.  Another  mode  of 
proceeding  is  to  press  the  curve  of  the  curette  against 
the  sclerotic  edge  of  the  section,  so  as  to  cause  the  wound 

to  gape  a  little,  at  the  same  time 
Fig.  21.     Fig.  22.    Fig.  23.    that  downward  traction  is  made 

rC\  on  the  globe  with  the  stead}^- 
Y  i^g  forceps.  If  after  cautiously 
trying  these  means,  the  edge  of 
the  lens  does  not  present  itself 
at  the  section,  or  if  an}'  vitre- 
ous should  escape,  a  blunt  hook 
or  a  cataract  spoon  must  be  em- 
ployed to  complete  the  extrac- 
tion. The  blunt  hook  used  by 
Graefe  is  of  the  form  repre- 
sented in  Fig.  22,  with  its  stem 
bent  as  in  Fig.  21,  to  enable  it 
be  readily  pushed  under  the 
nucleus.  I  prefer  mj-self  either 
Critchett's  or  Bowman's  spoon.  Figs.  15,  16,  17,  p.  164, 
or  the  traction  instrument  (Fig.  23)  designed  by  Mr. 
Taylor  of  Nottingham. 

5.  Clearing  the  Pupil  and  Coaptation  of  the  Wound. — 
If  any  soft  cortical  substance  remains  in  the  pupil,  a  little 
gentle  friction  and  pressure  with  the  finger  over  the 
closed  lids  will  generall}'  be  sufficient  to  cause  its  evacuti- 
tion — it  is  onl}'  in  very  exceptional  cases  that  a  scoop 
should  be  introduced  for  its  extraction.  The  wound 
should  now  be  cleared  with  the  iris  forceps  of  all  coagula, 


OPERATIONS  FOR  CATARACT.  167 

and  the  conjunctival  flap,  if  there  is  one,  be  restored  to 
its  proper  position. 

From  my  own  experience  I  can  speak  most  highly  of 
this  operation ;  and  prefer  it  to  all  others  when  the  patient 
is  both  able  and  willing  to  take  chloroform.  But  if,  from 
any  cause,  chloroform  is  inadmissible,  I  think  that  the 
ordinary  flap  extraction  is  safer.  The  details  of  Graefe's 
operation  require  to  be  so  delicately  executed,  and  the 
time  of  their  performance  is  comparatively  so  long,  that 
the  patient  will  often  lose  self-control,  and  by  his  unre- 
strained movements  greatly  jeopardize  the  eye. 

The  incision  which  I  make  in  this  operation  differs 
slightly  from  that  recommended  by  Graefe.  I  commence 
it  lower  down,  so  that  the  point  of  the  knife  enters  the 
margin  of  the  cornea  on  a  level  with  the  upper  edge  of 
the  pupil,  and  I  carefully  confine  the  section  to  the 
corneo-sclerotic  junction,  preferring  rather  to  invade  the 
cornea  than  to  trespass  on  the  sclerotic. 

There  are  other  operations  for  cataract  to  which  I  need 
only  refer.  They  have  each  been  strongly  advocated  by 
their  originators,  and  have  met  in  their  hands  with  a  cer- 
tain amount  of  success. 

Mooren's  Operation  for  the  Extraction  of  Cata- 
ract consists  in  making  an  iridectomy,  and  after  waiting 
from  a  foi'tnight  to  six  weeks  to  allow  the  eye  to  recover 
from  all  the  irritation  consequent  on  the  operation,  he 
performs  an  ordinary  flap  extraction.  The  preliminary 
iridectomy  should  be  upwards,  and  the  corneal  section 
should  be  afterwards  made  in  the  same  direction. 

Jacobson's  Operation  for  the  Extraction  of  Cata- 
ract combines  an  iridectomy  with  the  ordinary  flap  ex- 
traction. The  corneal  section  is  made  downwards  in  the 
corneo-sclerotic  junction.     After   the  lens   has  been  re- 


168  DISEASES    OF   THE    CRYSTALLINE    LENS. 

moved,  he  draws  out  with  a  pair  of  iris  forceps  the  cor- 
responding segment  of  the  iris,  and  excises  it  with  a  pair 
of  scissors.  There  are  two  great  objections  to  this  oper- 
ation : 

1st.  The  unseemh^  appearance  of  an  eye  in  which  an 
iridectomy  has  been  made  downwards. 

2d.  The  difficulty  which  must  always  ensue  from  ex- 
cising a  portion  of  the  iris  after  the  lens  has  been  re- 
moved. It  would  be  better  to  perform  the  iridectomy 
before  the  extraction  of  the  lens. 

Pagenstecher's  Operation  for  the  Extraction  of 
Cataract  differs  from  all  the  others  in  that  he  removes 
the  lens  in  its  capsule  entire".  He  makes  a  flap  incision, 
nsually  downwards,  and  entirely  through  the  sclerotic, 
leaving  a  small  bridge  of  conjunctiva  at  the  apex  of  the 
flap.  He  next  excises  a  large  segment  of  the  iris,  and 
then  completes  his  section  by  dividing  the  conjunctival 
bridge.  B^^  gentle  pressure  on  the  e3'e  he  now  endeavors 
to  urge  the  lens  in  its  capsnle  through  the  sclerotic  wound, 
but  should  he  fail  in  doing  so,  or  if  an}^  vitreous  should 
escape,  he  at  once  introduces  a  scoop  behind  the  lens,  and 
draws  it  out  of  the  eye  in  its  capsule.  Pagenstecher 
states  that  on  several  occasions  he  has  succeeded  in  thus 
extracting  the  lens  without  the  loss  of  anj"  vitreous,  not- 
withstanding that  in  some  of  the  cases  it  was  accom- 
plished by  the  aid  of  the  scoop.  He  also  refers  to  the  re- 
markable absence  of  iritis  after  this  operation, 

Macnamara's  Operation  for  Cataract. — The  follow- 
ing is  Mr.  Macnamara's  account  of  his  own  operation : 

"  The  pupil  having  been  fully  dilated  with  atropine,  the 
patient  laid  on  his  back,  and  placed  under  the  influence 
of  chloroform,  the  operator  adjusts  a  stop-speculum.  Sup- 
posing the  right  e^'e  is  to  be  operated  upon,  the  surgeon 


OPERATIONS  FOR  CATARACT.  169 

standing  behind  liis  patient  with  a  pair  of  toothed  forceps, 
seizes  the  internal  rectus,  so  as  to  steady  the  eyeball,  and 
in  the  other  hand  takes  a  short  and  broad-bladed  trian- 
gular knife,  and  thrusts  its  point  through  the  circumfer- 
ence of  the  cornea  a  little  within  its  margin.  The  blade 
of  the  knife  is  to  be  passed  steadily  onwards  nearly  up 
to  its  heel,  so  that  an  opening  is  made  through  the  cornea 
nearly  half  an  inch  in  extent.  As  the  blade  of  the  knife 
is  being  withdrawn  from  the  eye,  its  point  may  be  run 
into  the  lens  so  as  to  rupture  the  capsule.  The  knife 
being  laid  on  one  side,  but  the  speculum  and  hold  of  the 
internal  rectus  retained,  the  scoop  is  to  be  inserted  so  far 
into  the  anterior  chamber  as  to  enable  us  to  reach  the 
margin  of  the  pupil.  The  handle  of  the  instrument  being 
raised,  and  its  rounded  extremity  depressed,  the  latter 
evidently  rests  on  the  capsule  of  the  lens,  immediately 
within  the  margin  of  the  pupil.  The  scoop  is  now  to  be 
slightl}^  withdrawn,  still  keeping  its  extremity  on  the  lens, 
but  so  as  to  draw  open  the  pupil  far  enough  to  enable  us 
to  press  on  the  edge  of  the  lens  with  the  rounded  ex- 
tremity of  the  scoop.  The  instant  this  is  done,  the  lens 
tilts  over  on  its  axis,  and  the  scoop  being  thrust  onwards, 
the  lens  comes  to  lie  in  its  concavity,  and  ma}^  be  removed 
from  the  eye.  An}'  particles  of  lenticular  matter  remain- 
ing in  the  anterior  chamber  must  be  removed  with  the 
scoop  or  by  a  suction  instrument."* 

Treatment  of  the  Eye  after  an  Extraction  of  the 
Cataract. — After  the  operation  is  completed,  both  ej^e- 
lids  should  be  gently  closed,  and  a  Liebreich's  bandage 
(F.  1)  applied  ;  and  the  patient  should  be  then  placed  in 
bed  in  a  darkened  room  with  the  head  slightly  raised.  If 
the  case  progresses  favorably  the  patient  may  be  allowed 

*  Macnamara  on  Diseases  of  the  Eye,  p.  475. 
15 


170  DISEASES    OF    THE    CRYSTALLINE    LENS. 

to  get  up  after  thirty-six  hours,  aud  lie  on  a  sofa,  or  if  in 
a  hospital,  rest  on  the  outside  of  his  bed.  After  a  flap 
extraction  the  lids  should  not  be  opened  to  look  at  the 
e^'e  until  the  seventh  da}' ;  but  after  a  modified  linear,  or 
a  traction  operation,  the  eye  may  be  examined  with  safety 
on  the  third  or  fourth  day.  The  bandage  should  be 
changed  night  and  morning  as  the  flow  of  tears  renders 
the  linen  wet  and  uncomfortable.  If  the  lids  become 
gummed  together,  a  piece  of  linen  wet  with  tepid  water 
should  be  drawn  a  few  times  across  their  tarsal  borders, 
and  then  gently  pulling  down  the  lower  lid  with  one  finger, 
the}"  may  be  sufflcienth'  parted  to  allow  any  pent-up  tears 
to  escape.  If  the  patient  should  complain  that  the  cotton- 
wool pad  makes  the  eye  hot,  it  may  be  removed,  but  the 
fold  of  linen  over  the  ej-es,  and  the  bandage,  should  be 
continued.  After  about  eight  or  ten  days  the  bandage 
may  be  given  up,  aud  a  broad  shade  be  worn  over  both 
ej-es.  Three  or  four  times  during  the  da}^  the  lids  should 
be  bathed  with  tepid  water,  or  if  there  is  any  irritation, 
with  the  belladonna  lotion  (F.  32).  When  there  is  rest- 
lessness after  the  opei'ation,  an  opiate  should  be  given  at 
bedtime ;  and  if  the  patient  complains  of  severe  pain  in 
the  e^^e,  suflficient  to  prevent  sleep,  two  or  three  leeches 
should  be  applied  to  the  temple.  If  these  fail  to  give  re- 
lief, the  bandage  should  be  removed,  and  a  fold  of  linen 
wet  with  cold  or  iced  water  should  be  laid  over  the  closed 
lids.  A  mild  purgative  must  be  ordered  if  necessary,  so 
as  to  insure  the  regular  daily  action  of  the  bowels  with- 
out straining.  The  patient  should  be  allowed  his  regular 
diet,  with  the  exception  of  the  day  of  the  operation,  when 
I  generally  advise  only  beef-tea  and  farinaceous  food. 

The  Caslalties  which  may  occur  after  an  Extrac- 
tion OF  A  Hard  Cataract  are : 

1.  Prolapse  of  the  iris.     This  is  peculiar  to  the  flap  ex- 


OPERATIONS  FOR  CATARACT.  171 

traction,  and  to  those  operations  in  w^hich  no  portion  of 
the  iris  is  removed. 

2.  Iritis. 

3.  Suppuration  of  the  cornea. 

4.  Acute  ophthahnitis  and  suppuration  of  the  globe. 

5.  Imperfect  union  of  the  corneal  wound,  and  conse- 
quent fistula. 

6.  Cystoid  cicatrix. 

1.  Prolapse  of  the  iris  may  come  on  from  the  first  to 
the  fifth  day  after  a  flap  extraction,  and  sometimes  even 
later.  It  is  the  most  frequent  cause  of  failure  of  this  ope- 
ration, and  in  many  cases  seems  to  be  due  to  the  irrita- 
tion excited  b}^  some  cortical  lens  matter  left  in  the  pupil 
at  the  time  of  the  operation.  It  is,  however,  often  pro- 
duced b^^  some  spasmodic  action  on  the  part  of  the  patient, 
such  as  coughing  or  sneezing,  or  by  some  violent  emotion. 

Treatment. — At  first  apply  a  compress  bandage  (F.  2), 
and  leave  the  prolapse  alone.  If  after  a  fortnight  or  three 
weeks  the  prolapse  continues  large  and  shows  no  tendency 
to  subside,  it  may  be  pricked  at  two  or  three  points  with 
a  fine  needle,  and  the  compress  be  reapplied.  This  prick- 
ing operation  may  be  repeated  two  or  three  times  at  in- 
tervals of  three  or  four  days. 

2.  Ii'itis^  after  extraction,  is  usually'  chronic  and  serous. 
It  commences  as  a  rule  from  one  to  three  weeks  after  the 
operation.  It  is  always  accompanied  with  photophobia 
and  lachrj^mation,  and  frequently  with  the  edges  of  the 
lids  puffy,  thickened,  and  excoriated.  For  a  further  ac- 
count of  this  form  of  Iritis,  see  Traumatic  Iritis,  p.  102. 

Treatment. — Belladonna  to  the  eye  in  one  form  or  an- 
other to  relieve  pain  and  keep  the  pupil  dilated.  Tonics 
of  quinine  or  iron,  or  both  (F.  64,  65,  66)  should  be  given. 
Counter-irritation  in  the  form  of  small  blisters  the  size  of 
a  shilling  to  the  temple  or  behind  the  ear  occasionally  do 


172  DISEASES    OF    THE    CRYSTALLINE    LENS. 

good;  and  if  the  case  is  very  obstinate,  benefit  is  some- 
times derived  from  a  moderate  mercurial  inunction. 

Tlie  acute  iritis  is  comparatively  rare.  It  usuallv  fol- 
lows one  or  two  days  after  the  operation,  and  unless  soon 
arrested  it  may  lead  to  the  destruction  of  the  e^^e.  Occa- 
sionally it  will  partially  subside,  and  then  become  chronic. 

Treatment. — Leeches  to  the  temple  and  cold  a^jplica- 
tions  to  the  eye.  A  fold  of  linen  should  be  laid  over  the 
closed  lids,  and  be  moistened  with  iced  water  as  often  as 
it  becomes  hot  or  dry.  If  the  cold  ceases  to  be  grateful 
to  the  patient,  hot  fomentations  of  poppy -heads  or  bella- 
donna (F.  8,  9)  ma}^  be  substituted.  Diffusible  stimuli 
and  tonics  (F.  54,  63,  64)  should  be  ordered,  with  a  liberal 
diet,  and  opiates  be  given  if  necessar}'  to  relieve  pain  and 
produce  sleep.  Mercury  in  any  form  is  seldom  of  use  in 
these  cases ;  it  usuallv  depresses  the  patient  and  so  does 
absolute  harm.  In  the  acute  traumatic  iritis  which  fol- 
lows the  extraction  of  cataract,  there  is  a  strong  tendency 
for  the  inflammation  to  spread  to  the  neighboring  tissues, 
and  thus  to  drift  into  ophthalmitis  or  general  inflamma- 
tion of  the  ej'e. 

3.  Suppuration  of  the  cornea  ma}'  be  either  partial  or 
complete.  It  may  commence  in  the  line  of  tl\e  incision 
and  involve  more  or  less  of  the  corneal  flap,  to  which  it 
ma}'  be  limited ;  or  it  ma}-  be  diff'use,  and  include  the  en- 
tire cornea. 

Symptoms. — Increasing  pain  in  the  eye  and  around  the 
orbit ;  cedematous  swelling  and  redness  of  the  lids  ;  che- 
mosis  of  the  conjunctiva  and  a  muco-purulent  discharge. 

If  the  suppuration  is  ^ja7'/ia7  and  circumscribed.,  the 
line  of  the  incision  will  look  opaque  and  yellow,  and  there 
will  be  some  purulent  infiltration  extending  into  the  flap 
of  the  cornea,  whilst  the  lower  part  of  the  cornea,  although 
perhaps  slightly  tnrbid,  will  still  retain  some  of  its  trans- 
parency and  polish.     This  condition  of  the  eye  is  suf- 


OPERATIONS  FOR  CATARACT.  173 

ficient  to  create  great  anxiety  ;  but  if  the  suppuration  can 
be  confined  to  the  margin  of  the  wound,  it  is  not  hopeless. 
The  dangers  are,  firstty,  that  the  suppuration  will  become 
dittuse  ;  secondly,  that  it  will  extend  itself  to  the  deeper 
structures  and  induce  a  suppurative  inflammation  of  the 
globe ;  thirdly,  that  although  the  suppuration  of  the  cornea 
may  be  subdued,  a  secondary  iritis  or  irido-cyclitis  may 
follow,  which  will  in  the  end  produce  softening  and  atro- 
ph}^  of  the  globe. 

When  the  suppuration  of  the  cornea  is  diffuse  or  com- 
plete, the  symptoms  are  the  same  but  intensified.  The 
suppuration,  instead  of  being  confined  to  the  margin  of 
the  flap,  invades  the  whole  structure  of  the  cornea.  The 
eye  must  be  then  considered  as  irreparably  lost. 

In  old  and  feeble  patients  suppuration  of  the  cornea 
will  occasionally  occur  without  the  usual  inflammatory 
sjanptoms  of  pain  with  redness  and  swelling  of  the  lids 
being  manifested.  This  once  happened  to  a  poor  old 
woman,  who  had  long  been  an  inmate  of  a  workhouse,  on 
whom  I  operated  for  cataract.  With  only  a  sense  of 
grittiness  in  the  eye,  and  with  the  slightest  trace  of  swell- 
ing of  the  upper  lid,  partial  suppuration  of  the  cornea 
followed  on  the  fifth  or  sixth  day  after  the  operation. 

Treatment. — An  attempt  may  be  made  to  ward  off  the 
earh^  sj^mptoms  b}^  the  application  of  two  or  three  leeches 
to  the  temple,  and  iced  water  to  the  e^'e  ;  but  as  soon  as 
it  is  ascertained  that  suppuration  of  the  cornea  has  com- 
menced, a  different  treatment  should  be  adopted.  Warm 
fomentations  of  poppy-heads  or  belladonna  give  the  most 
relief,  and  may  be  used  every  two  or  three  hours,  and  in 
the  intervals  a  fold  of  lint  should  be  laid  over  the  eye  and 
kept  moist  with  warm  water  or  the  belladonna  lotion. 
Pain  should  be  relieved  by  repeated  doses  of  opium,  which 
may  be  combined  with  ammonia,  quinine,  or  liq.  cin- 
chonie»(F.  62).     The  patient  should  be  fed  up  with  such 

15* 


174  DISEASES    OF   THE   CRYSTALLINE    LENS. 

food  as  he  can  be  prevailed  on  to  take,  and  a  moderate 
allowance  of  wine  be  ordered  for  him.  A  compress  band- 
age (F.  2)  applied  to  the  eye  on  the  first  indication  of 
corneal  suppuration  is  often  of  service,  and  maj^  be  used 
jointh'  with  the  warm  applications,  the  bandage  being  re- 
moved three  or  four  times  daily  to  allow  of  the  fomenta- 
tions. If  the  pressure  be  painful,  it  should  not  be  per- 
severed in. 

4.  Acute  OjMhalniitis  aiid  Suppuration  of  the  Globe. — 
When  this  happens,  the  eye  is  lost,  and  the  only  course 
to  be  pursued  is  to  hasten  the  suppuration  by  warm  and 
soothing  applications ;  to  give  free  vent  to  the  pus  b}'  in- 
cision through  the  cornea  if  necessary ;  to  relieve  pain  by 
opiates  ;  and  to  support  the  patient  by  tonics,  stimulants, 
and  a  good  diet.    ' 

5.  Imperfect  Union  of  the  Corneal  Wound  and  conse- 
quent Fistula. — From  some  cause,  often  difficult  if  not 
impossible  to  explain,  the  wound  of  the  cornea  after  the 
extraction  of  cataract  fails  to  unite  completel}^,  and  a 
small  fistula  remains  through  which  the  aqueous  slowly 
dribbles. 

Treatment. — A  compress  bandage  (F.  2)  should  be 
placed  over  the  closed  lids,  and  twice  a  day  a  few  drops 
of  a  solution  of  atropine  gr.  1  ad  aqua;  ^  1  be  dropped 
into  the  eye.  This  tre'atment  generalh'  succeeds  in  closing 
the  fistula,  but  if  after  a  fair  trial  it  produces  no  efiect, 
the  opening  in  the  cornea  may  be  touched  with  a  fine 
camers-hair  brush  charged  with  nitrate  of  silver,  as  rec- 
ommended at    SLie  66. 

For  the  symptoms  and  further  treatment  of  corneal  fis- 
tula, see  Fistula  of  the  Cornea,  page  65. 

6.  Cystoid  Cicatrix. — This  can  only  occur  when  the 
incision  has  been  made  in  the  sclerotic.  It  is  due  to  the 
edges  of  the  wound  not  coming  into  close  contact,  and  to 
their  consequent  union  through  the  intervention  of  cica- 


CATARACT.  175 

tricial  tissue,  which  gradually  3'iekls  before  the  outward 
pressure  of  the  parts  within  the  e^e,  and  becomes  thinned 
and  bulging.  This  condition  of  the  cicatrix  in  the  scle- 
rotic will  be  occasionally  met  with  after  iridectomy  for 
glaucoma.  It  is  most  liable  to  happen  in  eyes  in  which 
there  is  an  increased  intraocular  tension. 

Treatment. — If  the  cj'stoid  cicatrix  is  small  or  gives  no 
inconvenience,  it  is  best  to  leave  it  alone.  When  large 
or  troublesome,  it  may  be  punctured  with  a  broad  needle. 
If  the  bulging  of  the  cicatrix  is  on  the  increase,  and  the 
tension  of  the  e3'e  is  glaucomatous,  an  iridectomy  should 
be  performed. 

Capsular  Cataract  is  a  misnomer.  There  cannot  be 
an  opaque  capsule  and  a  transparent  lens.  There  may  be 
an  opaque  and  chalky  capsule  containing  the  shrunken 
remains  of  a  lens,  or  there  may  be  an  opaque  capsule  fill- 
ing the  pupil  after  the  lens  from  some  cause  has  gone,  but 
neither  of  these  can  be  considered  as  examples  of  capsular 
cataract.  The  class  of  cases  to  which  the  term  can  be 
most  correctly  applied  are  those  in  which  there  are  spots 
or  patches  of  opacity  on  the  capsule  with  a  perfectly 
transparent  lens. 

These  local  opacities  may  exist  under  two  circum- 
stances : 

1st.  Patches  of  opacity  on  the  lens  capsule  may  be 
formed  from  inflammatory  exudations  during  iritis  or 
other  inflammations  of  the  eye.  They  are  usually  central 
and  correspond  to  the  pupil,  but  occasionally  ih.Qy  are  de- 
posited as  a  white  zone  around  the  margin  of  the  lens, 
and  can  be  only  detected  when  the  pupil  is  dilated. 

2d.  In  3'oung  children  one  or  more  white  spots  are 
occasionally  seen  on  the  lens  capsule,  the  lens  itself  being 
clear.  On  examining  the  cornea  of  such  ej'es  a  small 
nebula  will  be  frequently  found  to  correspond  with  the 


176  DISEASES    OF   THE    CRYSTALLINE    LENS. 

siaeck  on  the  lens  capsule;  and  on  inquiry  it  will  be  found 
that  these  patients  have  had  purulent  ophthalmia.  The 
inference  is  that  during  the  attack  the  swollen  cornea  and 
the  most  prominent  part  of  the  lens  came  together,  and 
that  the  capsule  at  the  point  of  contact  then  became 
opaque.  It  should  be  remembered  that  in  newl3'-born 
children  the  space  between  the  centre  of  the  lens  and  the 
cornea  is  so  small  as  hardly  to  deserve  the  name  of  an 
anterior  chamber.  When  the  centra]  capsular  opacity  is 
single  and  prominent,  it  has  been  called  j^y^^amidal  cata- 
ract. 

Capsulo-lenticular  Cataract. — ^In  this  form  of  cata- 
ract the  capsule  partakes  of  the  opacity.  It  may  not  be 
absolutely  opaque,  but  its  transparenc}'  is  so  atfected  that 
it  would  materially  interfere  with  vision  after  the  opaque 
lens  has  been  removed.  This  opacity  is  generally  con- 
fined to  the  anterior  layer  of  the  lens  capsule. 

Tr^eatment. — In  these  cases  the  plan  practised  by  Mr. 
Bowman  should  be  adoptecL  After  the  section  of  the 
cornea  has  been  completed  and  the  piece  of  iris  excised, 
if  an  iridectomy  has  to  be  performed,  instead  of  tearing 
through  the  lens  capsule  with  the  ordinary  pricker,  a  pair 
of  fine  iris  forceps  is  introduced  through  the  corneal 
wouhd,  and  seizing  hold  of  the  anterior  layer  of  the  cap- 
sule it  is  withdrawn  from  the  eye,  and  the  operation  of 
extraction  of  the  lens  is  then  completed  in  the  usual  wa}^ 

Diabetic  Cataract.  —  The  only  peculiarity  in  this 
variety  of  cataract  is  its  origin.  The  opaque  lens  pre- 
sents no  characteristic  to  distinguish  it  from  cataract 
arising  from  other  diseases  or  from  senile  decay.  As 
diabetes  frequently  attacks  young  people,  this  disease 
may  be  considered  as  one  of  the  causes  of  cataract  in 
early  life.     The  cataract  is  usually  soft,  but  this  is  due  to 


CATARACT.  177 

the  age  of  the  patient,  who  is  generally  below  the  period 
of  life  at  which  cataract  is  common.  In  diabetic  cataract 
the  opacit}^  is  prol)abl3'  dependent  on  impaired  nutrition. 
Treatment. — The  same  as  for  ordinary  cataract.  The 
l^resence  of  diabetes  has  been  urged  as  a  reason  for  not 
operating ;  but  if  the  patient  is  apparently  in  fair  health 
and  not  much  emaciated,  an  operation  is  certainly  not 
contraindicated.  I  have  on  several  occasions  operated 
myself  for  diabetic  cataract,  and  have  fi-equently  seen  my 
colleagues  do  so  at  the  Ophthalmic  Hospital,  and  in  no 
case  have  any  unfavorable  symptoms  followed. 

Fluid  Cataract  usually  occurs  in  joung  patients  and 
is  sometimes  congenital.  It  has  a  uniform  grayish-white 
milk-and-water  color  without  any  visible  strire  or  spots. 
The  fluidity  does  not  always  include  the  whole  lens ;  it 
occasionally  happens  that  within  a  fluid  and  diffluent  cor- 
tex there  is  a  small  firm  nucleus.  There  is,  however,  a 
form  of  fluid  cataract  which  is  met  with  in  elderly  people, 
which  seems  to  be  an  advanced  stage  of  degeneration  of 
the  lens.  The  lenticular  matter  is  converted  into  a  semi- 
transparent  3-ellowish  fluid,  which  contains  oil  globules 
and  sometimes  plates  of  cholesterine.  In  some  excep- 
tional cases  the  fluid  is  of  a  dark  chocolate  or  sepia  color. 
Mr.  Ilaynes  Walton  relates  the  case  of  a  lady,  ffit.  77,  on 
whom  he  operated,  in  which  the  "capsule  did  not  contain 
a  particle  of  lens,  but  was  filled  with  material  like  coffee 
grounds."* 

Treatment. — The  same  as  for  other  forms  of  cataract. 
If  after  the  section  has  been  made  in  the  cornea  and  the 
lens  capsule  opened  with  the  pricker,  the  lenticular  matter 
is  found  to  be  fluid,  it  may  be  either  sucked  out  with  a 
syringe  or  allowed  to  escape  along  the  groove  of  a  curette. 

*  Surgical  Diseases  of  the  Eye,  2d  edition,  p.  512. 


178  DISEASES    OF    THE    CRYSTALLINE    LENS. 

Traumatic  Cataract,  or  cataract  the  result  of  an  in- 
jury to  the  eye,  may  occur  either  with  or  without  a  rup- 
ture of  the  external  coats  of  the  eye. 

1.  Traumatic  Cataract  with  Rupture  of  the  External 
Coats  of  the  Eye. — One  of  the  most  frequent  complica- 
tions of  a  wound  of  the  cornea  is  an  injury  to  the  lens. 
Wounds  of  the  lens  terminate  almost  invariably  in  cata- 
ract. The  point  of  injury  is  within  twenty-four  hours  in- 
dicated by  an  opaque  patch,  and  this  opacitA"  gradually 
increases  until  the  whole  lens  becomes  opaque.  The 
rapidity  of  the  formation  of  the  cataract  will  depend 
partly  on  the  extent  of  the  injur}^  inflicted  on  the  lens 
and  its  capsule,  and  parti}'  also  on  the  age  of  the  patient. 
If  the  rent  in  the  capsule  is  large,  and  the  lenticular 
matter  has  also  been  broken  into,  the  aqueous  humor  will 
be  rapidly  brought  into  contact  with  the  lens  substance, 
and  its  transparency  will  be  quickly  destroj-ed.  In  the 
young,  the  lens  is  soft,  and  becomes  more  rapidly  cata- 
ractous  from  an  injury  than  in  the  aged,  where  it  is  more 
dense  and  has  a  firm  nucleus.  A  wound  of  the  lens  is 
ver}'  commonh'  associated  with  a  prolapse  or  laceration 
of  the  iris,  or  with  both:  indeed  it  is  more  usual  for  it  to 
be  accompanied  with  some  lesion  of  the  iris,  than  for  the 
injury  to  be  confined  to  the  lens.  The  immediate  effect 
of  a  wound  of  the  lens  is  the  admission  of  the  aqueous 
within  its  capsule.  This  is  imbibed  hy  the  lens  tissue, 
each  part  of  which  becomes  opaque,  and  rapidly  swells  as 
it  is  brought  under  the  influence  of  the  aqueous ;  so  that 
the  swelling  of  the  lens  increases  with  the  opacity  until 
the  whole  is  opaque.  The  lens  thus  swelling  frequently 
presses  on  the  posterior  surface  of  the  iris,  and  excites 
great  irritation :  hence  it  is  of  the  utmost  importance  that 
the  pupil  should  be  kept  fnlly  dilated  with  atropine,  in 
order  to  aftbrd  space  for  the  swelling  lens,  and  to  prevent 
as  far  as  possible  its  encroaching  on  the  iris. 


CATARACT.  179 

The  irritation  which  is  tlius  excited  by  a  cataractous 
lens  is  greater  and  more  apt  to  occur  in  the  adult  and 
aged  person  than  it  is  in  the  child.  The  most  serious 
S3'mptom  which  the  pressure  of  a  swollen  lens  on  the  back 
of  the  iris  is  apt  to  produce  is  a  glaucomatous  hardness  of 
the  globe — a  condition  known  as  '•''traumatic  glaucoma^ 
It  is  ushered  in  with  increased  pain  and  irritation ;  the 
anterior  chamber  is  diminished  in  size  from  the  lens 
having  pushed  the  iris  forwards  towards  the  cornea;  the 
e.je,  has  a  pinkish  tinge  from  a  general  fulness  of  the 
sclerotic  vessels,  but  especially  of  those  which  form  the 
ciliary  zone,  and  the  tension  of  the  globe  is  increased. 
This  state  of  eye  is  fraught  with  danger,  and  alwa3^s  de- 
mands immediate  treatment. 

2.  Traumatic  Cataract  ivithout  Rupture  of  the  External 
Goats  of  the  Eye. — Sudden  violence  against  the  ej^e,  or 
to  the  bony  parts  which  surround  it,  may  cause,  without 
any  rupture  of  the  external  coats  of  the  eye,  a  rent  in  the 
capsule  of  the  lens  sufficient  to  allow  the  aqueous  to  per- 
meate its  structure  and  to  render  it  cataractous.  Yon 
Graefe  has  noticed  that  in"  such  cases  the  rent  is  generally 
at  the  periphery  of  the  lens,  or  within  the  area  of  the  thin 
posterior  capsule,  but  never  in  the  middle  of  the  anterior 
capsule. 

Again,  a  blow  on  the  eye  ma}',  without  any  apparent 
injury  of  the  lens  capsule,  so  disarrange  the  internal 
structure  of- the  lens  that  its  nutrition  will  become  im- 
paired, and  as  a  result  its  transparency  will  be  destroyed. 
This  accident  is  more  rare  than  the  preceding,  in  which 
the  lens  capsule  is  torn.  The  form  of  cataract  which  is 
usually  produced  is  a  diffused  opacit}';  a  portion  of  the 
lens  first  becomes  nebulous,  and  this  nebulosity  increases 
until  the  whole  lens  is  opaque. 

Treatment  of  Traumatic  Cataract. — 1.  If  the  cataract 
is  uncomplicated  with  injury  to  the  iris,  and  has  been 


180  DISEASES    OF    THE    CRYSTALLINE    LENS. 

caused  by  some  fine  shai'p-pointed  instrument  penetrat- 
ing the  cornea,  there  is  good  reason  to  hope  for  a  favor- 
able result.  A  solution  of  atroi:)ine,  gr.  1  ad  aquae  ^  1 
should  be  dropped  twice  or  three  times  a  day  into  the  eye 
to  dilate  the  pupil  fully,  and  thus  to  keep  the  iris  out  of 
the  way  of  the  swelling  lens.  A  compress  and  bandage 
should  be  fastened  over  the  closed  lids,  or,  if  it  is  more 
comfortable,  a  fold  of  linen  wet  with  cold  water,  or  the 
belladonna  lotion  (F.  32)  may  be  laid  over  the  eye.  If 
there  is  pain  in  the  eye  or  around  the  orbit,  two  leeches 
should  be  at  once  applied  to  the  temple.  The  patient 
should  be  kept  in  a  darkened  room.  If  after  all  the  irri- 
tation occasioned  by  the  injury  has  subsided,  a  gradual 
absorption  of  the  lens  matter  is  found  to  be  going  on,  it 
is  wise  not  to  meddle  with  the  cataract,  but  to  keep  a 
careful  watch  over  the  e}' e,  and  be  prepared  to  treat  symp- 
toms as  the}^  arise,  being  guided  b}^  them  in  the  future 
management  of  the  case. 

2.  If  the  wound  in  the  lens  is  complicated  with  injury 
to,  or  jjrolapse  of  the  iris,  attention  must  first  be  directed 
to  the  iris,  which,  if  prolapsed,  will  require  to  be  dealt 
with  in  one  of  the  wa3's  suggested  under  the  heading 
Prolapse  of  the  Iris.  The  general  treatment  recom- 
mended in  the  preceding  section  must  be  also  adopted 
here,  and  if  no  untoward  symptoms  arise,  the  cataractous 
lens  must  be  left  untreated  until  the  eye  has  quite  recov- 
ered from  the  primary  shock  of  the  injury.    - 

Whenever  a  traumatic  cataract  excites  great  irritation 
or  induces  s3^mptoms  of  traumatic  glaucoma,  the  lens 
should  be  at  once  removed.  The  operation  to  be  selected 
will  depend  on  the  density  of  the  lens,  the  general  con- 
dition of  the  eye,  and  the  age  of  the  patient.  As  a  rule, 
when  the  lens  is  soft,  a  linear  extraction  or  a  suction 
operation  should  be  performed.     Either  of  these  opera- 


CAPSULAR    OPACITIES.  181 

tions  may  be  combined  with  an  iridectom}-  if  circnm- 
stances  render  it  advisable. 

If,  howeA^er,  the  patient  is  advanced  in  years,  and  the 
lens  consequently  more  or  less  hard,  the  best  operation 
will  be  either  the  modified  linear  extraction  or  the  trac- 
tion operation. 

Secondary  Cataract  is  when  the  opacity  of  the  lens 
is  dependent  on,  and  secondary  to,  disease  of  the  vitre- 
ous, choroid,  or  retina.  In  these  cases  the  lens  not  only 
grows  opaque,  but  frequently  undergoes  a  further  degen- 
eration, and  earthy  salts,  the  carbonate  and  phosphate  of 
lime,  are  deposited  both  in  it  and  in  its  capsule.  The 
appearance  of  such  a  lens  is  ver}^  characteristic.  It  is 
usually  somewhat  shrunken  and  flattened,  with  a  peculiar 
o^Daque  chalky  look,  and  either  strikingly  white  or  tinged 
slightly  with  j^ellow.  It  is  often  associated  with  other 
degenerative  changes  within  the  eye,  and  occurs  con- 
jointly with  bony  formations  on  the  choroid  and  second- 
ary detachments  of  the  retina. 

Treatment Secondary  cataracts,  as  a  rule,  are  best 

left  alone.  In  the  majority  of  cases,  the  eye,  when  the 
cataract  is  complete,  is  blind,  and  the  extraction  of  the 
lens  would  give  no  improvement  of  sight.  Even  in  the 
most  favorable  instances,  where  there  is  some  perception 
of  light,  and  a  moderately  active  pupil,  the  fundus  of  the 
eye  is  usually  so  unsound  that  it  is  always  doubtful 
whether  the  slight  chance  of  benefit  is  sufficient  to  justify 
the  risk  of  an  operation.  Certainly,  wnen  the  patient  has 
one  eye  good,  no  operation  for  the  extraction  of  the 
opaque  and  chalky  lens  should  be  performed. 

capsular  opacities. 

Capsular   Opacities   following   the    Loss   of  the 
Lens — After  the  lens  has  been  removed,  either  by  ab- 
le 


182  DISEASES    OF   THE    CRYSTALLINE    LENS. 

sorption  or  extraction,  some  densit}^  of  the  capsule  wliicli 
has  been  left  is  very  apt  to  occur,  and  to  greatly  mar  the 
excellence  of  vision  which  the  patient  would  otherwise 
possess.  The  degree  of  opacity  varies  very  much,  and  is 
dependent  on  different  circumstances. 

The  simplest  form  of  opacity  of  the  capsule  is  that 
which  often  occurs  after  an  operation  for  the  removal  of 
the  lens,  especially  after  linear  or  suction  extraction.  Its 
formation  is  unaccompanied  with  any  inflammatory  ac- 
tion. Examined  with  the  ophthalmoscope,  a  film  of  cap- 
sule will  be  found  occupying  the  pupillary  space,  not 
actuall}^  opaque,  but  with  its  transparency  sufficiently 
dulled  to  interfere  with  the  due  passage  of  the  light  to 
the  fundus  of  the  eye.  Mr.  Bowman  has  shown  that  the 
capsule  may  cause  a  serious  imperfection  of  sight  without 
becoming  opaque,  by  assuming  a  wrinkled  and  folded 
state,  so  as  to  produce  an  unequal  refraction  of  light  in 
its  passage  through  it,  and  a  consequent  confusion  of  the 
image  on  the  retina. 

The  second  form  of  opacity  of  the  capsule  is  where  the 
membrane  itself  is  semi-opaque ;  but  its  opacity  is  con- 
siderably increased  by  bits  of  soft  lenticular  matter 
having  become  inclosed  between  parts  of  the  anterior 
and  posterior  layers  of  the  capsule.  If  the  pupil  be 
dilated  with  atropine,  the  opacity  of  the  capsule  will  be 
seen  to  vary  in  density  in  different  points  of  its  area, 
according  to  the  quantity  of  lens  matter  which  has  been 
inclosed  between  its  laj^ers.  This  form  of  opacity  js  not 
necessarily  accompanied  with  any  inflammatory  action. 

Dr.  Schweigger,  of  Berlin,  has  shown  that  the  opacit}^ 
of  the  lens  capsule  may  also  be  increased  by  an  imperfect 
growth  of  those  intracapsular  cells,  which  from  some 
cause  have  escaped  the  action  of  the  aqueous  on  them. 

The  third  form  of  ojmcity  of  the  capsule  is  always  asso- 
ciated with  iritis.     Lymph  is  eflused  on  the  surface  of 


CAPSULAR    OPACITIES.  183 

the  capsule,  and  adhesions  more  or  less  extensive  between 
it  and  the  iris  close  the  pupil.  The  capsule  itself  becomes 
opaque,  and  blending  with  the  l^mph  upon  its  surface 
grows  tough,  and  almost  fibrous  in  its  structure,  losing 
all  its  natural  elasticit}^  This  state  of  the  capsule  is  very 
frequently  combined  with  some  soft  opaque  lens  sub- 
stance shut  in  between  its  layers  ;  indeed  in  many  cases  it 
is  due  to  the  irritation  which  has  been  excited  from  some 
lenticular  matter  having  been  left  behind  at  the  time  of 
the  operation  for  the  extraction  of  the  lens. 

It  is  this  form  of  membranous  opacity  which  frequently 
undergoes  after  a  lapse  of  time  a  degeneration  of  struc- 
ture :  in  some  cases  losing  the  toughness  it  at  first  ac- 
quired, it  becomes  brittle  and  friable,  allowing  a  needle 
or  a  pair  of  iris  forceps  to  pass  through  it  like  tinder ;  or 
it  may  in  after  years  become  the  seat  of  earthy  deposits. 
The  second  form  of  capsular  opacity  I  alluded  to,  where 
a  portion  of  lenticular  matter  is  inclosed  between  the  lay- 
ers of  the  capsule,  is  also  liable  to  degenerative  changes, 
and  to  have  earthy  salts  deposited  in  the  vestiges  of  the 
lens  between  its  folds. 

Treatment  of  Capsular  Opacities. — In  treating 
opacities  of  the  capsule  after  the  lens  has  been  removed, 
it  may  be  taken  as  a  rule  which  should  never,  if  possible, 
be  departed  from,  that  no  operation  should  be  performed 
so  long  as  the  eye  is  red  or  irritable. 

Needle  Operation  for  Opaque  Capsule. — A  single  nee- 
dle is  usually  sufficient  to  tear  an  opening  through  the 
semi-opaque  or  wrinkled  capsule  which  is  often  found 
after  an  ordinary  operation  for  cataract,  but  two  needles 
should  be  in  readiness  in  case  a  second  is  required. 

Before  commencing  the  operation  the  pupil  should  be 
fully  dilated  with  atropine.  The  needle  should  penetrate 
the  cornea  obliquely  about  one  or  one  and  a  half  lines 


184  DISEASES    OF   THE    CRYSTALLINE    LENS. 

from  its  circumference,  and  passing  across  the  pupil  to 
the  opposite  side,  it  should  puncture  the  capsule  close  to 
the  iris,  and.  by  then  slightl}'  depressing  tlie  hand,  the 
needle  is  made  to  dip  a  little  into  the  vitreous,  and  to 
cut  its  way  through  the  capsule.  In  some  eyes  one  or 
two  dips  of  the  needle  will  suffice  to  make  a  clear  opening 
in  the  capsule,  whilst  in  other  cases  they  have  to  be  re- 
peated mau}^  times. 

Occasionally  it  happens,  that  after  the  needle  has  made 
an  opening  through  the  capsule,  an  adherent  film  remains 
stretching  across  the  pupil,  which  a  single  needle  fails  to 
divide.  A  second  needle  should  then  be  used,  after  the 
manner  first  recommended  by  Mr.  Bowman.  It  should 
be  introduced  by  the  other  hand  thi'ough  the  cornea  at 
a  point  nearly  opposite  to  the  first ;  and  passing  its  point 
behind  the  band,  whilst  that  of  the  first  needle  remains 
in  front  of  it,  so  that  their  points  cross,  the  one  needle 
is  made  to  revolve  a  few  turns  over  the  other,  until  the 
band  of  capsule  is  torn;  or  if  this  does  not  readily  follow, 
the  two  needles  nia^^  be  then  slightly  but  slowly  sepa- 
rated; a  proceeding  which  will  seldom  fail  in  breaking  it 
through. 

In  cases  where  there  is  some  lens  matter  inclosed  be- 
tween the  anterior  and  posterior  layers  of  the  capsule,  a 
needle  operation  such  as  has  been  alread}^  described  will 
generally  be  sufficient.  The  breaking  up  of  the  capsule 
will  expose  the  particles  of  lens  matter  to  the  action  of 
the  aqueous,  and  they  will  usually  be  quickly  absorbed. 

When  there  has  been  iritis,  and  the  pupil  is  closed  with 
a  dense  membrane,  a  new  pupil  may  be  formed  and  the 
capsule  torn  through  with  two  needles  ;  but  this  will  not 
alwaj'S  suffice,  as  iritis  will  often  follow  the  operation 
and  the  pxipil  will  again  become  closed.  It  is  generally 
necessary,  after  the  capsule  has  been  torn  through,  to  re- 
move a  portion  of  the  iris  and  make  a  false  pupil. 


CAPSULAR   OPACITIES.  185 

To  use  two  Needles^  to  tear  through  the  Opaque  Capsule 
and  open  out  the  closed  Pupil — One  needle  is  to  be  in- 
troduced through  one  side  of  the  cornea,  and  be  passed 
into  the  centre  of  the  capsule  upon  which  the  pupil  is 
contracted  and  adherent.  The  second  needle  is  to  pene- 
trate the  opposite  side  of  the  cornea,'  and  to  be  inserted 
also  into  the  capsule  close  to  the  first.  The  points  of  the 
two  needles  are  now  to  be  dipped  downwards  a  little  into 
the  vitreous,  and  to  be  drawn  slowly  in  opposite  direc- 
tions, so  as  to  tear  through  the  capsule,  and  at  the  same 
time  to  pull  open  the  pupil.  Having  done  this,  the 
needles  are  to  be  withdrawn,  and  according  to  the  size 
of  the  pupil  which  has  been  formed  must  depend  the  ne- 
cessitj-  of  making  an  artificial  pupil  by  removing  a  piece 
of  the  iris.  If  the  new  pupil  does  not  open  out  sufli- 
cientlj',  it  will  be  well  at  once  to  make  an  opening  in  the 
cornea  with  a  broad  needle,  and  with  a  Tyrrell's  hook 
(Fig.  6,  p.  114)  to  draw  out  a  piece  of  the  iris  and  cut  it 
off. 

The  most  difficult  cases,  however,  of  all  to  treat  are 
those  in  ivhich  there  is  a  piece  of  tough  milky-xchite-look- 
ing  lens  capsule  occupying  the  pupillary  area,  and  to 
which  the  iris  is  adherent  at  points.  The  normal  elas- 
ticity of  such  a  portion  of  capsule  has  been  lost,  and 
oftentimes  some  of  the  earthy  salts  are  found  to  be  in- 
coq^orated  with  it,  or  with  the  remains  of  the  little  len- 
ticular matter  which  has  been  inclosed  between  its  layers. 
A  needle  operation  here  would  do  no  good. 

There  are  two  modes  of  dealing  with  such  cases : 

1.  Having  fully  dilated  the  pupil  with  atropine,  detach 
the  opaque  capsule  from  its  adhesions  to  the  iris  by  a  fine 
needle  introduced  through  the  cornea.  This  being  done, 
the  fine  needle  is  to  be  withdrawn,  and  the  opening  it  has 
made  is  to  be  enlarged  with  a  broad  needle  to  allow  of 
the  introduction  within  the  anterior  chamber  of  the  canu- 

16* 


186 


DISEASES    OF   THE    CRYSTALLINE    LENS. 


FfG.  24. 


lar  forceps  (Fig.  24),  with  which  tlio  piece  of  capsule  is 
to  be  seized  and  drawn  out  of  the  eye.  If, 
on  drawing  out  the  oi)aque  capsule  through 
the  aperture  in  the  cornea,  a  point  of  it  is 
found  still  adherent  to  the  iris,  that  which 
has  b^en  withdrawn  should  be  snipped  off 
with  a  pair  of  scissors,  but  no  attempt  should 
be  made  to  detach  it  by  force.  This  opera- 
tion is  a  very  hazardous  one^  though  the  re- 
sult when  success  follows  is  very  brilliant. 
The  great  danger  consists  in  the  dragging 
upon  the  iris  and  the  ciliary'  processes.  I 
have  occasionally  seen  suppuration  of  the 
globe  follow  this  operation. 

2.  The  second  plan  which  may  be  adopted, 
and  in  many  cases  it  is  a  very  safe  and  efll- 
cient  one,  is  first  to  make  an  iridectomy  of 
a  moderate  size,  selecting  that  part  of  the 
iris  which  is  either  free,  or  has  the  least  ad- 
hesions to  the  capsule  in  the  pu pillar}'  space. 
A  piece  of  opaque  capsule  will  be  then  seen 
occupying  the  greater  part  of  the  area  of 
the  new  pupil.  Through  the  wound  in  the 
cornea  the  blades  of  a  pair  of  fine  iris  scis- 
sors may  be  introduced,  and  passing  one 
blade  in  front  of  the  opaque  capsule,  and 
the  other  behind  it,  with  three  clips  a  triangular  piece 
may  be  cut  out,  which  may  be  lifted  away  by  a  pair  of 
forceps.  A  clear  space  may  thus  be  made  for  the  free 
passage  of  light  into  the  eye  with  far  less  danger  than  by 
forcibly  removing  the  opaque  capsule  entire. 

After  all  operations  for  capsular  opacities,  the  eje 
should  be  kept  for  at  least  three  or  four  days  with  the 
pupil  full}'  dilated  with  atropine. 


DISLOCATIONS    OF   THE    LENS.  187 

dislocations  of  the  lens. 

Dislocation  of  the  Lens  into  the  Anterior  Cham- 
ber may  be  either  congenital,  or  the  result  of  an  injury, 
such  as  a  blow  on  the  eye^  or  on  the  head  in  the  vicinity 
of  the  eye.  Occasionally  it  is  caused  by  excessive  retch- 
ing or  coughing,  but  in  such  cases  it  will  generally  be 
found  on  inquiry  that  the  eyes  were  unsound,  and  pre- 
disjoosed  to  this  accident. 

Symptoms. — A  transparent  lens  Ijang  in  its  capsule  in 
the  anterior  chamber  presents  a  iDeculiar  and  charac- 
teristic appearance.  It  looks  like  a  large  drop  of  oil  lying 
at  the  back  of  the  cornea,  the  margin  of  the  lens  exhib- 
iting a  brilliant  yellow  reflex.  The  iris  is  pushed  back- 
wards, and  the  anterior  chamber  is  thus  greatly  deepened. 
The  pupil  is  always  more  or  less  dilated  in  proportion  to 
the  amount  of  pressure  the  lens  exerts  upon  the  iris.  The 
lens  in  this  abnormal  position  acts  as  a  foreign  body.  It 
is  productive  of  great  irritation,  and  of  severe  pain.  The 
inflammation  which  so  frequently  follows  this  accident 
may  be  partially  due  to  other  parts  of  the  eye  having 
suffered  from  the  primary  injury;  but  much  must  also  be 
attributed  to  the  pressure  of  the  lens  on  the  iris. 

The  pain  which  accompanies  this  displacement  of  the 
lens  is  usually  severe  and  neuralgic  in  character,  often- 
times more  intense  than  the  state  of  the  eye  would  lead 
us  to  anticipate  ;  but  the  pressure  on  the  iris,  and  conse- 
quently on  the  ciliary  nerves,  is  sufficient  to  account  for 
its  severity. 

Treatment  of  Dislocation  of  the  Lens  into  the  Anterior 
Chamber. — If  the  lens  is  giving  rise  to  irritation,  it  should 
undoubtedly  be  removed,  and  as  soon  as  possible  :  the  ir- 
ritation will  probably  continue  and  increase  if  it  is  allowed 
to  remain  in  its  abnormal  position.  But  if  the  lens,  al- 
though lying  in  the  anterior  chamber,  is  not  acting  as  an 


188  DISEASES    OF   THE   CRYSTALLINE    LENS. 

irritant,  and  the  eye,  when  seen  by  the  surgeon,  is  per- 
fectl}'  quiet  and  free  from  undue  vascularity,  what  course 
should  be  pursued  ?  To  answer  this  question,  it  is  nec- 
essary first  to  consider  what  are  the  present,  and  what 
are  likel}^  to  be  tlie  ultimate  effects  of  such  an  accident. 
There  are  two  results  which  generally  follow  the  long- 
continued  presence  of  the  lens  in  the  anterior  chamber, 
viz.,  paralysis  and  atrophy  of  the  iris :  both  of  tliese  are 
due  to  the  one  cause,  pressure  of  the  lens  on  the  iris. 
They  are  not  the  immediate  results  of  a  dislocated  lens, 
but  they  are  the  sequences  of  the  prolonged  pressure 
Avhich  is  kept  up  by  the  lens  against  the  iris,  when  it  has 
been  allowed  to  remain  for  many  months  or  years  in  con- 
tact with  it.  Now  although  the  eye  when  first  seen  may 
be  quiet  and  free  from  all  vascular  excitement,  yet  it  is 
impossible  to  say  how  long  this  quiescent  state  may  last. 
An  outbreak  of  acute  inflammation  may  occur  at  any  time 
without  any  special  assignable  cause  beyond  the  abnormal 
pressure  of  the  lens  on  the  iris.  Again,  the  presence  of 
the  lens  in  the  anterior  chamber  is  very  apt  to  give  rise 
to  a  glaucomatous  state,  under  which  the  tension  of  the 
globe  becomes  suddenly  increased,  and  the  pain  very 
severe.  This  condition  is  alwaj's  one  of  peculiar  danger 
to  the  eye,  and  calls  at  once  for  active  treatment. 

Considering  then  the  many  casualties  which  may  hap- 
pen to  an  eye  with  a  dislocated  lens  lying  in  its  anterior 
cliamber,  I  believe  it  is  advisable  in  all  cases  to  remove  it. 

In  children  a  suction  operation  or  a  linear  extraction 
maybe  performed.  It  is  generally  judicious  in  such  cases 
to  complete  the  extraction  of  the  lens  in  one  sitting,  rather 
than  to  divide  it  into  two  stages,  with  an  interval  of  some 
days  between  them,  as  in  the  ordinary  mode  of  perform- 
ing suction  and  linear  operations. 

If  the  patient  is  an  adult,  or  a  person  advanced  in  years, 
the  dislocated  lens  should  be  removed  by  a  traction  ope- 


DISLOCATIONS    OF   THE    LENS.  189 

ration,  or  hy  Graefe's  linear  extraction.  Having  made 
the  section  in  the  corneo-sclerotic  junction,  either  witli  a 
large  keratome  or  with  Graefe's  cataract  knife,  and  if 
possible  excised  a  portion  of  the  iris,  the  lens  should  be 
taken  away  in  its  capsule,  with  the  aid  of  one  of  the  trac- 
tion instruments,  page  164,  or  with  the  skeleton  spoon, 
Fig.  23,  or  with  a  sharp  hook,  which  may  be  made  to  seize 
hold  of  it,  and  draw  it  from  the  eye.  During  the  opera- 
tion an  escape  of  vitreous  will  probably  occur,  as  the  sus- 
pensory ligament  must  have  been  torn  to  allow  of  the  lens 
being  dislocated,  and  this  could  hardly  have  been  ac- 
complished without  at  the  same  time  some  rupture  of  the 
hyaloid  membrane. 

Dislocation  of  the  Lens  into  the  Vitreous. — This 
accident  may  occur  either  with  or  without  rupture  of  the 
external  coats  of  the  eye. 

The  lens  is  usually  dislocated  inclosed  in  its  capsule, 
which  may  be  either  entire  or  partially  lacerated.  If  the 
capsule  has  been  torn,  the  lens  will  soon  become  cata- 
ractous  ;  but  even  if  it  is  entire,  the  lens  generally  after 
some  months  becomes  opaque,  on  account  of  its  due  nu- 
trition being  interfered  with. 

If  the  dislocation  has  been  complete^  the  iris,  having 
lost  the  support  of  the  lens,  will  fall  slightly  backwards 
towards  the  vitreous,  and  thus  increase  the  depth  of  the 
anterior  chamber.  The  iris  will  also  generally  be  found 
tremulous,  its  whole  surface  vibrating  with  the  move- 
ments of  the  QyQ. 

If,  however,  the  dislocation  has  not  been  quite  complete, 
but,  as  is  usually  the  case,  some  shreds  of  the  suspensory 
ligament  still  connect  the  lens  in  its  capsule  with  the 
upper  region  of  the  globe,  then  the  lower  surface  of  the 
iris  against  which  the  lens  presses  will  be  bulged  towards 
the  cornea,  whilst  the  plane  of  the  upper  part  will  be  un- 


190  DISEASES    OF   THE    CRYSTALLINE   LENS. 

altered.  When  the  lens  is  thus  suspendedy  it  may  be 
sometimes  seen  by  the  unaided  e3'e,  but  always  b}'  focal 
illumination,  hanging  by  film}'  shreds  from  the  upper  sur- 
face of  the  globe,  and  swaying  to  and  fro  with  the  motions 
of  the  e3'e. 

State  of  the  Pupil. — There  is  always  more  or  less  dila- 
tation of  the  pupil.  This  is  probabl}'  chiefly  due  in  most 
cases  to  the  injur}- which  the  ciliary  nerves  have  sustained 
in  the  accident,  although  it  may  also  be  partly  accounted 
for  by  the  pressure  which  the  displaced  lens  often  exerts 
on  the  lower  segment  of  the  iris. 

The  general  symptoms  are  those  of  great  irritation. 
There  is  increased  vascularity,  with  dread  of  light,  lach- 
rymation,  and  pain.  The  eye,  from  the  first  effects  of  the 
injury,  becomes  actively  inflamed,  but  this  state,  under 
treatment,  may  gradually  subside.  It  is,  however,  gen- 
erally succeeded  by  a  low  form  of  choroido-iritis  or  cho- 
roido-retinitis,  which  is  kept  up  by  the  irritation  caused 
by  the  abnormal  position  of  the  lens.  In  this  stage  a 
glaucomatous  state  frequently  supervenes,  and  the  ten- 
sion of  the  eye  becomes  greatly  increased.  With  fhe  in- 
crease of  tension,  all  the  symptoms  become  aggravated  ; 
and  unless  the  lens,  the  source  of  the  irritation,  is  re- 
moved, the  loss  of  the  eye  is  certain.  This  glaucomatous 
condition  is  liable  to  occur  in  all  the  dislocations  of  the 
lens  icithin  the  eye,  but  it  is  more  prone  to  follow  those 
in  which  the  lens  is  either  partially  or  completely  dis- 
placed behind  the  iris  than  when  it  is  thrown  in  front  of 
that  structure. 

Treatment  of  Dislocation  of  the  Lens  into  the  Vitreous. 
— If  the  dislocation  is  complete,  and  the  eye  is  free  from 
irritation,  it  should  be  left  alone,  but  the  patient  should 
be  kept  under  careful  supervision.  If,  however,  the  dis- 
placed lens  is  exciting  inflammation,  it  should  be  re- 
moved.    This  is  best  done  by  a  traction  operation.    (See 


DISLOCATIONS    OF   THE   LENS.  191 

page  162.)  An  opening  having  been  made  in  the  corneo- 
sclerotic  junction,  the  lens  should  be  extracted  with  a 
medium-sized  spoon.  There  is,  however,  one  difficulty 
which  besets  this  operation  when  performed  for  the  ex- 
traction of  a  dislocated  lens  from  the  vitreous.  It  is  often 
impossible  to  seize  hold  of  the  iris  to  draw  it  out  of  the 
wound  preparatory  to  excising  a  portion  of  it ;  for,  hav- 
ing lost  the  support  of  the  lens,  it  will  sometimes  fall 
backwards,  and  get  so  behind  the  cut  edge  of  the  sclerotic 
that  the  forceps  cannot  be  made  to  grasp  it.  This  diffi- 
culty is  increased  by  an  escape  of  vitreous,  which  almost 
invariably  takes  place  immediately  on  the  withdrawal  of 
the  knife  from  the  eye,  and  is  dependent  on  a  rupture  of 
the  h^^aloid  at  the  time  of  the  accident,  which  has  allowed 
the  vitreous  to  fall  forwards.  If,  therefore,  the  attempt 
to  seize  and  draw  out  a  piece  of  iris  is  unsuccessful,  it  is 
better  at  once  to  abandon  it,  afid  to  go  on  with  the  oper- 
ation, as  the  repeated  introduction  of  the  forceps  within 
the  eye  will  cause  a  large  and  unnecessary  amount  of 
vitreous  to  be  lost. 

Dislocation  of  the  Lens  beneath  the  Conjunctiva 
can  only  occur  in  cases  where  the  sclerotic  has  been  rup- 
tured, but  the  conjunctiva  over  the  rent  has  remained 
entire.  The  lens,  separated  by  the  violence  of  the  injury 
from  its  ciliary  attachment,  is  forced  out  of  the  eye 
through  the  wound,  and,  as  the  conjunctiva  has  not  been 
lacerated,  it  will  be  seen  lying  beneath  it.  The  disloca- 
tion is  almost  invariably  upwards,  or  upwards  and  in- 
wards, as  it  is  in  the  upper  region  of  the  eye,  between 
the  insertion  of  the  recti  muscles  and  the  margin  of  the 
cornea,  that  the  split  of  the  sclerotic  coat  most  frequently 
occurs. 

Symptoms. — The  lens  will  be  seen  lying  beneath  the 
conjunctiva,  forming  a  small,  roundish,  semi-transparent 


192  DISEASES   OF   THE    CRYSTALLINE   LENS. 

swelling.  If  the  anterior  chamber  is  clear,  the  altered 
shape  of  the  pupil,  probably  also  the  tremulous  state  of 
the  iris,  and  "the  presence  of  a  subconjunctival  tumor, 
will  be  sufficient  evidence  of  the  nature  of  the  accident. 
The  lens  is  nearly  always  dislocated  inclosed  in  its  cap- 
sule ;  but  owing  to  the  rough  manner  in  which  it  is 
squeezed  through  the  aperture  in  the  sclerotic,  the  cap- 
sule is  often  lacerated,  and  the  lenticular  matter  fre- 
quently somewhat  comminuted. 

Treatment. — When  the  lens  is  seen  lying  beneath  the 
conjunctiva,  it  should  be  removed;  and  this  may  be  done 
by  making  a  small  incision  through  the  conjunctiva  either 
with  a  cataract  knife  or  with  a  pair  of  fine  scissors,  and 
then,  if  the  lens  is  entire  in  its  capsule,  by  at  once  lifting 
it  out;  or  if  its  capsule  has  been  broken  and  its  substance 
comminuted,  carefully  taking  it  away  piecemeal  with  a 
small  scoop,  paying  special  regard  that  fragments  of  it 
are  not  left  between  the  lips  of  the  wound  of  the  sclerotic 
to  interfere  with  its  primary  union.  The  lids  should  be 
then  closed,  and  a  cotton-wool  compress  with  a  light 
bandage  be  applied  to  the  e3^e. 

It  will  be  well,  as  a  precautionary  measure,  to  apply 
two  or  three  leeches  to  the  temple,  and  for  a  few  days  to 
keep  the  patient  on  a  slightl}^  antiphlogistic  regimen. 

Partial  Dislocations  of  the  Lens  may  occur  from 
blows  on  the  eya  or  the  side  of  the  head,  when  a  portion 
only  of  the  suspensory  ligament  is  detached,  and  conse- 
quently a  limited  or  only  partial  displacement  of  the  lens 
ensues. 

1.  The  lens  may  be  dislocated  either  partially  upwards 
or  partially  downwards,  and  in  either  position  it  may  con- 
tinue permanently  fixed.  Occasionally  the  lens  is  found 
to  be  slightly  tilted  without  an}'  absolute  displacement ; 


DISLOCATIONS    OF    THE    LENS.  193 

one  margin  is  pressed  forwards  against  the  iris,  whilst  the 
other  is  forced  back  into  the  vitreons. 

2.  The  suspensory  ligament  may  have  been  torn  or 
partially  detached  at  one  part  of  its  cii'cumference ;  and 
although  no  immediate  displacement  of  the  lens  may  have 
followed,  yet,  owing  to  this  loosening  or  partial  detach- 
ment of  its  ligament,  it  may  have  become  what  is  called 
a  movable  or  swinging  lens,  swaying  backwards  and  for- 
wards with  the  movements  of  the  head  or  the  eye.  In 
certain  postures  of  the  head,  as  in  looking  downwards  or 
in  stooping  forwards,  a  partial  dislocation  of  the  lens 
through  the  pupil  may  take  place ;  whilst  with  the  head 
erect,  as  in  looking  directly  forwards  or  upwards,  the 
lens  may  sink  back  behind  the  pupil  to  apparently  its 
normal  position.  Independentlj^  of  the  intraocular  symp- 
toms which  such  a  swinging  lens  is  liable  to  excite,  a 
serious  defect  in  vision  will  be  produced  by  the  frequent 
changes  in  the  position  of  the  lens,  such  as  to  render  the 
e3'e  not  only  comparatively  useless,  but  a  source  of  very 
considerable  annoyance  and  even  of  danger  to  the  patient 
by  causing  him  to  misjudge  and  confuse  objects  with 
which  he  may  come  in  contact  in  his  daily  work. 

General  Symptoms. — Partial  displacements  of  the  lens 
are  generally  accompanied  by  grave  symptoms.  The  blow 
required  to  produce  such  an  injury  must  be  one  of  con- 
siderable force,  and  the  mere  laceration  of  the  suspensory 
ligament,  irrespective  of  the  irritation  which  the  malposi- 
tion of  the  lens  may  give  rise  to,  is  sufficient  to  place  the 
eye  for  a  time  in  some  danger.  But  when  all  the  first 
symptoms  which  may  be  attributed  to  the  blow  have 
passed  awaj',  there  often  remain  severe  neuralgic  pains 
in  the  eye.  and  around  the  orbit,  wiiich  in  some  instances 
are  persistent,  though  var}- ing  in  intensit}^,  whilst  in  other 
cases  they  are  recurrent,  with  intervals  of  perfect  ease. 
The  sight  is  always  materially  affected,  as  in  proportion 

17 


194  DISEASES    OF   THE   CRYSTALLINE    LENS. 

to  the  tilting  forwards  of  the  lens  the  patient  becomes 
myopic.  The  lens  ma}^  continue  transparent  for  a  long 
time  after  the  injury,  but  the  general  rule  is  for  it  sooner 
or  later  to  become  cataractous. 

The  most  alarming  condition  which  a  partially  dis- 
placed lens  is  likely  to  produce  is  a  state  of  glaucoma, 
which  may  come  on  at  any  period  after  the  accident.  In 
such  cases  the  glaucomatous  symptoms  are  generally  more 
or  less  recurrent ;  for  the  increased  tension  of  the  eye, 
being  dependent  on  pressure  on  the  back  of  the  iris,  is 
produced  whenever  the  lens  falls  forwards  against  that 
structure,  and  gradually  subsides  when  this  pressure  is 
removed  by  a  change  of  the  position  of  the  lens.  A  fre- 
quent repetition  of  this  glaucomatous  condition  will,  how- 
ever, speedily  induce  such  changes,  that  unless  means 
are  adopted  to  arrest  it,  total  loss  of  sight  must  in  the 
end  be  the  result. 

Treatment  of  partial  Displacements  of  the  Lens. — If 
the  lens  is  partially  dislocated  and  fixed,  and  the  eye  is 
quiet,  it  may  be  satisfactorily  treated  by  Wecker's*  plan 
of  performing  an  iridodesis,  so  as  to  draw  the  iris  over 
the  edge  of  the  displaced  lens,  and  thus  making  the  new 
pupil  correspond  to  the  space  in  which  the  lens  is  want- 
ing. The  patient  afterwards  will,  of  course,  require  cata- 
ract glasses  for  near  and  distant  vision. 

If  the  lens  from  partial  detachment  of  its  suspensory 
ligament  is  a  swinging  or  movable  one,  and  is  causing 
personal  inconvenience  from  frequently  dropping  par-  . 
tially  through  the  pupil,  and  thus  producing  a  confusion 
of  the  patient's  vision,  even  though  there  is  no  pain,  its 
extraction  should  be  advised. 

If  glaucomatous  symptoms  come  on,  the  removal  of 
the  lens  becomes  an  absolute  necessity  for  the  safety  of 

*  "W^ccker,  Muladies  dos  Yeux,  2d  edition,  p.  477. 


HYPERiEMIA    OF   THE    RETINA.  195 

the  eye,  and  an  operation  for  its  extraction  should  be 
performed  with  as  little  delay  as  possible. 

The  choice  of  the  operation  for  the  removal  of  the  lens 
in  these  cases  lies  betweeen  the  ordinar}^  extraction  with 
a  large  corneal  flap,  the  modified  linear  extraction,  and 
the  traction  operation.  In  either  operation  a  certain 
amount  of  vitreous  must  be  lost,  as,  with  the  rupture  of 
the  suspensory  ligament,  the  hyaloid  is  certain  to  have 
been  broken,  and  a  portion  of  the  vitreous  will  neces- 
saril}'^  escape  either  immediately  before  or  else  directly 
following  the  exit  of  the  lens  from  the  eye.  In  all  cases 
in  which  a  glaucomatous  state  has  followed  a  displace- 
ment of  the  lens,  the  traction  operation  should  be  per- 
formed, as  the  excision  of  a  portion  of  the  iris  will  help 
to  restore  the  eye  to  its  normal  tension.  But,  in  addition 
to  this,  the  lens  will  be  removed  through  a  comparatively 
small  opening,  and  the  risk  of  posterior  hemorrhage, 
which  is  always  great  when  the  ordinary  flap  extraction  is 
performed  on  glaucomatous  eyes,  will  be  thus  prevented. 


CHAPTER  V. 

DISEASES   OP   THE   RETINA,    CHOROID,    AND   OPTIC   NERVE. 

Hyperemia  of  the  Retina. — In  estimating  the  de- 
gree of  vascularity  of  the  retina,  the  fundus  of  the  dis- 
eased eye  should  be  compared  with  that  of  the  sound  one, 
as  fulness  of  the  vessels,  if  equally  present  in  both  ej'cs, 
would  clearly  not  account  for  a  special  defect  in  one  of 
them.  Hyperoemia  may  be  caused  by  overworking  the 
eyes,  and  especially  if  they  are  hypermetropic,  or  myopic; 
or  it  may  come  on  from  the  repeated  exposure  to  bright 


196  DISEASES    OF    THE    RETINA. 

lights  ;  or  it  may  be  associated  with  inflammation  of  any 
part  of  the  eye.  The  fundus  looks  too  red,  and  the  optic 
nerve  has  a  decidedly  pinkish  aspect.  The  patient  com- 
plains of  occasional  flashes  of  light,  and  an  inability  to 
continue  his  accustomed  work  for  an}-  length  of  time,  from 
a  sense  of  fatigue  and  heat  in  the  ej^es.  I  have  seen  this 
condition  of  the  eyes  in  seamstresses,  bootbinders,  engra- 
vers, and  amongst  the  Spitalfields  weavers,  who  are  often 
engaged  for  many  hours  at  close  work  with  an  inefficient 
light.  It  is  occasionally  associated  with  hypersesthesia, 
or  undue  sensibility  of  the  retina.  The  63^6  is  thus  ren- 
dered intolerant  of  bright  light,  and  frequently  during 
the  day  the  lids  are  spasmodically  closed  from  sudden 
gushes  of  hot  tears  acccompanied  with  a  sense  of  gritti- 
ness  and  increased  photoph(;bia.  These  paroxysms  usu- 
ally last  only  two  or  three  minutes,  when  the  eyes  return 
to  the  condition  they  were  in  before. 

A  more  serious  form  of  hyperfemia  is  a  passive  venous 
congestion  due  to  some  impediment  in  the  return  flow  of 
blood.  It  is  seen  in  impairments  of  sight  due  to  the 
presence  of  tumors  within  the  orbit  or  the  skull,  or  to 
some  local  congestion  of  the  brain.  It  occurs  in  cases 
of  acute  amaurosis  dependent  on  suppressed  menstrua- 
tion, and  it  will  be  also  found  in  all  glaucomatous  affec- 
tions. 

Treatment. — For  the  first-mentioned  form  of  hyperemia 
of  the  retina,  rest  of  the  eyes  is  imperative.  The  patient 
should  abstain  from  all  work  which  requires  close  appli- 
cation of  the  eyes  or  a  stooping  position  of  the  head,  and 
he  should  wear  blue  glasses  when  exposed  to  any  glare 
or  artificial  light.  One  or  two  leeches  applied  to  the 
temple,  and  repeated  at  intervals  of  two  or  three  days, 
are  often  of  service ;  and  mild  counter-irritation  behind 
the  ears,  or  to  the  temple,  by  the  repeated  application  of 
small  blisters  or  a  stimulating  liniment,  will  occasionally 


RETINITIS.  197 

do  good.  As  the  congestion  is  often  due  to  some  impair- 
ment of  the  sympathetic  nerve,  which  from  some  canse 
fails  to  exert  its  proper  influence  in  maintaining  a  due 
tonicity  of  the  vessels,  preparations  of  iron,  the  mineral 
acids,  and  bark,  are  frequently  of  the  greatest  benefit. 
As  a  local  application,  the  cold  douche  is  the  best.  It' 
should  be  applied  to  the  eyes  with  the  lids  closed. 

For  the  second  form  of  hyperemia,  the  treatment  must 
necessarily'  be  very  unsatisfactory.  When  there  is  rea- 
sonable evidence  to  suppose  that  it  is  caused  by  a  tumor 
within  the  skull,  medicine  can  do  little  if  any  good.  The 
iodide  or  bromide  of  potassium,  singl}^  or  combined,  may 
be  tried ;  but  my  own  experience  is  that  they  are  seldom 
of  any  benefit. 

Retinitis  or  Inflammation  of  the  Retina,  gener- 
ally arises  from  some  constitutional  cause,  as  syphilis,  or 
disease  of  the  kidneys ;  but  it  may  also  be  produced  by 
over-use  of  the  eyes  before  strong  lights.  It  may  occur 
as  a  secondary  affection  from  obstruction  to  the  I'etinal 
circulation,  from  orbital  tumors,  or  from  embolism,  or 
from  an  extension  of  an  inflammation  of  the  neighboring 
structures.  So  intimately  associated  are  the  retina  and 
choroid  in  health,  that  it  is  difficult  for  one  to  be  affected 
b}'  disease  without  the  other  also  participating.  In  speak- 
ing, therefore,  of  the  diseases  of  the  retina,  it  must  not 
be  inferred  that  the  retina  only  is  affected,  but  that  it  is 
the  structure  primarily  involved,  and  the  seat  of  the  prin- 
cipal morbid  changes.  As  in  iritis,  1  will  flrst  describe 
the  general  symptoms  of  retinitis,  and  then  briefly  refer 
to  the  special  peculiarities  which  mark  the  various  forms 
of  this  disease. 

General  Symptoms. — The  patient  complains  that  he 
sees  surrounding  objects  darkl}',  as  though  he  were  look- 
ing through  a  mist.     He  has  to  examine  closely  whatever 

17* 


198  DISEASES    OF   TUB    RETINA. 

he  wishes  to  see  correctly,  and  to  use  a  strong  light ;  in 
fact,  from  the  dulled  sensibility  of  the  retina  a  deep  im- 
pression is  required.  As  the  disease  progresses,  the  field 
of  vision  becomes  contracted,  or  portions  of  it  are  lost ; 
and  the  darkness  steadily  increases  until  ultimately  the 
eye  is  blind.  The  defect  of  sight  is  influenced  by  the 
part  of  the  retina  which  is  chiefly  affected ;  when  the 
peripheral  portions  are  first  attacked,  the  field  of  vision 
is  contracted,  but  the  impairment  of  sight  is  much  less 
than  when  the  region  of  the  yellow  spot  is  invaded  by 
the  disease.  The  external  appearance  of  the  eye  is  un- 
changed, there  is  nothing  about  it  to  strike  the  ordinary 
observer ;  it  is  onl}^  b}^  the  ophthalmoscope  that  the  sj-mp- 
toms  complained  of  by  the  patient  can  be  explained. 

Examined  with  the  opJithahnoscojye,  there  is  seen  a 
change  in  the  transparency  of  the  retina,  which  is  slightly 
turbid  or  milk}^,  from  a  delicate  film  of  exudation  on  its 
surface.  There  is  usually  some  swelling  of  the  optic  disc, 
its  outline  is  indistinct,  and  looks  blended  with  the  sur- 
rounding parts.  The  veins  are  generall}'  more  or  less 
distended  and  sometimes  tortuous,  and  parts  of  them  are 
here  and  there  rendered  less  distinct,  on  account  of  the 
film  Avhich  covers  them.  There  ma}^  be  extravasations  of 
blood,  or  inflammatory  exudation  into  the  retinal  tissue, 
wdiich  will  appear  as  grayish-white  spots. 

llie  lorognoais  of  retinitis,  except  when  it  proceeds 
from  syphilis,  is  generally  unfavorable.  The  prospect  of 
recovery  is  diminished  in  proportion  to  the  extent  of  the 
hemorrhages,  and  the  amount  of  the  inflammatory  exu- 
dations. Nerve  structure  once  destroyed  is  never  re- 
placed. It  is  only,  therefore,  when  the  exudations  have 
been  chiefly  confined  to  the  connective  tissue  of  the  retina 
that  a  favorable  result  will  follow.  When  there  has  been 
neither  hemorrhage  nor  isolated  graj'  spots  of  exudation, 
the  eye  may  recover  with  fair  sight.     Retinitis  may  ter- 


RETINITIS.  199 

minate  in  blindness  from  atrophy  of  the  retina,  or  by  its 
detachment  from  the  choroid. 

Treatment. — For  that  form  of  retinitis  whicli  is  ap- 
parently unconnected  either  with  syphilis  or  disease  of 
the  kidney,  small  alterative  doses  of  the  hydrarg.  per- 
chlorid.  (F.  80)  may  be  given  two  or  three  times  a  day;  or 
the  iodide  or  bromide  of  potassium  (F.  74,  79),  may  be 
prescribed,  and  at  the  same  time  slight  counter-irritation 
may  be  kept  up  by  rubbing  into  the  temple  every  night  a 
little  of  the  unguent,  hydrarg.  biniodid.  (F.  105).  The 
eyes  should  be  allowed  absolute  rest,  and  this  can  be  ob- 
tained b}^  the  patient  abstaining  from  all  close  work,  and 
b}^  wearing  spectacles  with  glasses  of  a  rather  dark  cobalt 
blue.  If  the  retinitis  can  be  traced  to  overwork,  or  has 
come  on  after  fever  or  any  seA'ere  illness,  tonics  of  quinine, 
iron,  or  cinchona  with  the  mineral  acids  should  be  ordered, 
with  rest  to  the  e3^es,  and,  if  possible,  change  of  air. 

Retinitis  Albuminurica — Nephritic  Retinitis. — This 
form  of  retinitis  has  received  the  name  of  "  albuminurica," 
from  being  frequently  associated  with  renal  disease,  when 
the  urine  is  charged  with  albumen.  It  usually  occurs  in 
patients  who  have  Bright's  disease  of  the  kidney,  and, 
consequent  on  it,  an  hypertrophy  of  the  left  ventricle  of 
the  heart. 

Symptoms. — There  are  two  forms  in  which  this  nephritic 
retinitis  may  occur.  1.  It  may  gradually  develop  itself 
with  the  advance  of  the  kidney  disease.  For  a  long  time 
the  patient  may  have  complained  of  a  general  mistiness, 
everything  appearing  as  if  through  a  veil ;  or  the  impair- 
ment of  vision  may  have  been  confined  to  one  portion  of 
the  field,  when  suddenly  the  sight  is  discovered  to  be 
markedl}'  worse.  The  whole  field  may  be  thus  affected, 
so  that  the  eye  is  almost  dark  ;  or  the  blindness  may  be 
partial.     This  sudden  loss  of  sight  is  probably  due  to 


200  DISEASES   OF   THE   KETINA. 

retinal  hemorrhage,  and  is  in  proportion  to  the  number, 
size,  and  locality  of  the  blood-clots. 

2.  The  second  form  of  nephritic  retinitis  is  dependent 
on  uraemia,  and  occurs  in  the  later  stages  of  kidney  dis- 
ease, associated  with  suppression  of  urine,  delirium,  and 
convulsions.  The  loss  of  sight  is  very  rapid  and  some- 
times permanent.  If  no  organic  changes  have  taken  place 
in  the  retina  from  hemorrhage  during  the  attack  of  urtemic 
poisoning,  the  patient  may  gradually  regain  much  of  his 
sight  after  the  kidneys  have  resumed  their  functions  ;  but 
the  prognosis  is  always  unfavorable. 

Ophthalmoseojnc  aj)pearance.s. — The  optic  nerve  is 
slightly  swollen  and  cedematous,  with  its  margin  indis- 
tinct and  blurred  into  the  surrounding  cloudy  retina. 
Around  the  disc  the  retina  looks  of  a  grayish  white,  and 
the  vessels  as  the3'  pass  to  and  from  the  optic  nerve  are 
in  parts  obscured  by  the  exudation.  At  various  points  of 
the  retina  butt-colored  patches  are  seen,  and  in  the  neigh- 
borhood of  the  yellow  spot,  small  whitish  glistening  bodies 
appear  sprinkled.  The  retinal  veins  are  distended  and 
tortuous,  and  there  are  numerous  small  eff'usions  of  blood 
scattered  over  the  retina.  The  hemorrhage  is  always 
from  the  capillaries,  and  this  no  doubt  is  due  to  the  mor- 
bid state  of  the  coats  of  the  A^essels  in  advanced  Bright's 
disease,  and  to  the  increased  force  by  which  an  hj'per- 
trophied  heart  sends  the  blood  through  them. 

Mr.  Hulke  has  had  two  opportunities  of  dissecting  eyes 
aflected  with  chronic  renal  retinitis,  an  account  of  which 
he  published  in  the  "  Ophthalmic  Hospital  Reports. "  * 
He  found  there  was  : 

"  1.  (Edematous  swelling  of  the  optic  nerve  and  retina. 
"  2.  Large  granular  corpuscles,  more  or  less  abundant, 
mostly  in  the  intergrauule  layer. 

*  Koyal  London  Uiilitliahnic  Hospital  Keports,  vol.  v,  p.  IG. 


RETINITIS.  201 

"  3.  Botryoidal  masses  of  colloid,  also  in  this  laj'er. 

"  4.  Xests  of  sclerosed  and  enlarged  ganglionic  cells, 
or  raoniliformly  swollen  and  sclerosed  nerve-fibres  in  the 
ganglionic  and  opticus  layers, 

"  5.  Hemorrhages  :  the  shape  of  the  patches  of  the 
extraA'asated  blood  being  determined  b}'  the  arrangement 
of  the  tissues  into  which  the  blood  escapes." 

It  has  been  said  that  bj^  the  presence  of  retinitis  albu- 
minurica,  the  surgeon  may  at  once  diagnose  with  the 
ophthalmoscope  Bright's  disease ;  but  it  should  be  remem- 
bered that  the  affection  of  the  eyes  is  secoudar}-  to  that 
of  the  kidnej's ;  and  that  it  is  only  in  advanced  cases  of 
the  disease  that  the  sj^mptoms  are  sufficiently  marked  to 
do  more  than  point  to  the  kidneys  as  the  probable  source 
of  the  mischief. 

Treatment As  the  state  of  the  eyes  is  secondary  to, 

and  dependent  on,  the  disease  of  the  kidneys,  the  treat- 
ment must  be  constitutional,  and  those  remedies  should 
be  selected  which  are  suitable  for  the  renal  affection  from 
which  the  patient  is  suffering.  The  bowels  should  be 
made  to  act  onge  daily,  the  pulv,  jalapse  comp.,  or  some 
hydragogue  cathartic  being  given  early  in  the  morning 
when  necessary.  The  preparations  of  iron  usuall}'  do 
good,  and  of  these  the  tinct,  ferri  perchlorid,  is  perhaps 
the  most  useful.  The  object  to  be  attained  is  to  relieve 
the  kidneys  by  promoting  the  action  of  the  skin  and  the 
bowels.  Mercury  in  any  form,  in  nephritic  retinitis, 
should  be  strictly  avoided.  If  the  eye  is  painful,  a  leech 
applied  to  the  temple  will  often  give  ease,  and  it  ma}^  be 
repeated  from  time  to  time.  The  patient  should  strictly 
rest  the  eyes,  and  protect  them  from  all  exposure  to  glare 
or  artificial  light,  and  for  this  purpose  he  should  wear 
spectacles  with  curved  cobalt-blue  glasses.  He  should 
also  avoid  stooping,  as  it  favors  the  flow  of  blood  to  the 


202  DISEASES    OF   THE    RETINA. 

eyes,  aiul  thus  renders  them  more  liable  to  retinal  hemor- 
rhages. 

Retinitis  Syphilitica There  is  one  form  of  retinitis 

which  is  undoubted!}'  due  to  syphilis.  The  history  of  the 
case  and  certain  ophthalmoscopic  appearances  mark  its 
specific  origin.  It  nsually  occurs  during  the  tertiary 
period  of  S3philis,  when  nodes  form  on  the  bones,  and  the 
patient  has  pains  in  his  limbs  and  joints;  when  in  fact 
the  constitution  has  been  thoroughly  imbued  with  the 
poison.  Mr.  Hutchinson*  has  shown  that  choroido-reti- 
nitis  may  arise  also  from  inherited  syphilis. 

Symptoms. — A  gradual  fading  of  the  sight  extending 
over  the  whole  field  of  vision.  The  pupil  is  sluggish  and 
inclined  to  be  dilated.  There  are  no  external  manifesta- 
tions to  account  for  the  great  loss  of  sight.  A  past  his- 
tory ma}^  reveal  syphilis,  or  there  may  be  local  evidences 
of  the  disease  which  will  render  a  searching  interrogation 
unnecessar}^ 

Examined  tvitJi  the  Ophthalmoscope. — There  is  usually 
turbidity  of  the  vitreous,  and  a  diflTused  gra^'ish  haze  of 
tlie  retina  extending  from  around  the  optic  disc;  whilst 
here  and  there  are  seen  buff-colored  patches  of  exuda- 
tion. The  absence  of  an}'  hemorrhagic  spots  are  also  to 
some  extent  characteristic  of  syphilitic  retinitis. 

Pure  and  uncomplicated  sj-philitic  retinitis  is  a  rare 
disease ;  it  is  usually  combined  with  exudative  choroid- 
itis, and  to  the  joint  affection  of  the  retina  and  choroid, 
the  term  "  syphilitic  choroido-retinitis "  has  been  well 
applied.     See  Exudative  Choroiditis,  p.  217. 

The  prognosis  of  retinitis  syphilitica  is  more  favorable 
than  that  of  any  of  the  other  forms  of  retinitis.  When 
seen  sufficiently  early,  the  disease  will  generally  j'ield  to 

*  Syphilitic  Diseases  of  the  Eye  and  Ear,  p.  130. 


RETINITIS   SYPHILITICA.  203 

appropriate  treatment,  and  a  great  amelioration  of  the 
symptoms  will  usually  folloAv,  and  in  some  cases  a  com- 
plete restoration  of  sight. 

Treatment. — The  iodide  of  potassium  and  the  prepara- 
tions of  mercury  are  the  drugs  to  be  relied  on  for  the  re- 
lief of  this  disease.  I  have  found  the  mist,  potassii  iodidi 
cum  hydrarg.  perchlorid.  (F.  78)  extremely  beneficial,  and 
have  had  patients  recover  under  its  influence  in  a  most 
marked  way.  This  mixture,  however,  is  very  apt  to  dis- 
agree with  the  stomach,  and  to  produce  a  feeling  of  dis- 
comfort, and,  in  many  instances,  to  bring  out  an  attack 
of  mercurial  erythema,  which  induces  the  most  intolerable 
irritation  when  the  patient  is  warm  in  bed,  and  obliges 
him  to  desist  from  the  medicine.  It  is  most  easily  toler- 
ated if  it  is  taken  about  one  or  two  hours  after  a  meal. 
When  the  progress  of  S3'philitic  retinitis  is  very  rapid,  it 
is  desirable  to  get  the  patient  quickly  under  the  influence 
of  mercur^^,  and  this  may  be  readily  accomplished  by 
rubbing  half  a  drachm  of  the  unguent,  hjxlrarg.  into  the 
axilla  or  inner  side  of  the  thighs  night  and  morning  until 
the  gums  are  slightly  affected,  when  its  eflTects  may  be 
continued,  without  being  increased,  by  diminishing  the 
frequency  of  the  inunction.  If  the  patient  is  feeble,  qui- 
nine may  be  given  during  the  exhibition  of  the  mercury; 
but  if  not,  small  doses  of  the  iodide  of  potassium  two  or 
three  times  a  day  will  be  the  most  useful.  In  some  cases 
I  have  seen  very  good  results  follow  the  use  of  Mr.  Henry 
Lee's  mercurial  vapor  bath  (F.  3).  The  patient  should 
commence  his  fumigations  with  gr.  10  of  calomel,  and 
continue  them  every  night,  the  surgeon  keeping  a  careful 
watch  that  he  does  not  become  too  much  affected  by  them. 
The  baths  should  be  discontinued  or  intermitted  if  the 
gums  become  spongy.  During  the  day  the  patient  may 
take  the  iodide  of  potassium  (F.  74)  ;  or,  if  his  strength 
is  failing  him,  he  may  be  prescribed  quinine  or  cinchona 


204  DISEASES    OF   THE    RETINA. 

with  nitric  acid.  The  mercurial  baths  are  most  efficient 
during  the  summer  months,  when  the  skin  acts  freel}', 
and  when  there  is  the  least  liability  of  the  patient  getting 
chilled  after  taking  them.  I  should  not  order  the  baths 
during  the  cold  months  unless  the  patient  was  able  to 
have  them  in  his  own  bedroom,  and  provide  himself 
against  all  risks  of  exposure  either  during  or  after  their 
administration. 

Retinal  Apoplexy — Hetimfis  apoplectica. — Retinal 
hemorrhage  ma}'  occur  from  disease  within  the  eye,  as  in 
retinitis  or  glaucoma;  but  it  may  also  come  on  from  some 
extrinsic  cause,  and  it  is  this  form  of  intraocular  hemor- 
rhage we  have  now  to  consider. 

Sudden  hemorrhage  from  the  rupture  of  a  retinal  or 
choroidal  vessel  ma}'  arise  from  a  diseased  state  of  the 
heart,  or  an  atheromatous  condition  of  the  coats  of  the 
vessels,  or  from  embolism,  or  from  suppressed  menstrua- 
tion. It  may  happen  also  in  young  patients,  who,  with- 
out any  evidence  of  disease,  have  a  morbid  tendency  to 
bleed,  and  exhibit  this  predisposition  by  frequent  attacks 
of  epistaxis.  In  such  cases  the  liability  to  retinal  hemor- 
rhage is  favored  if  the  daily  employment  necessitates  a 
stooping  position  of  the  head.  A  well-marked  example 
of  this  form  of  retinal  hemorrhage,  apparently  due  only 
to  a  peculiar  hemorrhagic  tendency,  came  under  my  care 
at  the  hospital  in  a  young  fellow,  aet.  19,  who  was  by  occu- 
pation a  currier.  He  was  accustomed  to  work  for  many 
hours  with  his  body  bent,  and  his  head  stooping  forwards. 
About  eight  weeks  previously  to  my  seeing  him  he  was 
at  his  usual  employment,  and  after  his  day's  work  went 
to  bed  feeling  quite  well ;  but  on  getting  up  in  the  morn- 
ing he  was  so  blind  that  he  could  scarcely  find  his  way 
to  the  work-yard;  and  in  about  two  hours  he  was  obliged 
to  return  home,  as  he  had  only  sufficient  sight  to  guide 


Rl<:TrNAL    APOPLEXY.  205 

himself  about.  The  boy  had  suftered  from  repeated  at- 
tacks of  epistaxis,  and  only  a  week  before  he  had  lost  a 
large  quantity  of  blood  from  the  nose.  Examined  with 
the  ophthalmoscope,  there  was  seen  extensive  retinal 
hemorrhage  in  each  eye.  There  were  dark  clots  in  the 
vitreous  of  both  eyes,  and  in  the  left  a  ruptured  retinal 
vessel  could  be  distinctly  made  out. 

Symptoms. — Occasionally  there  are  the  premonitory 
warnings  of  a  disturbed  circulation  ;  the  patient  has  at- 
tacks of  giddiness  and  dimness  of  vision  which  may  last 
from  a  few  seconds  to  a  few  minutes ;  he  complains  of 
pain  in  his  head,  or  has  bleeding  from  the  nose ;  but  in 
many  cases  the  retinal  hemorrhage  occurs  suddenly  with- 
out an}'  previous  indication  of  existing  disease.  The  sud- 
denness of  the  loss  of  sight  is  one  of  the  most  character- 
istic symptoms.  The  patient  may  awake  in  the  morning 
and  find  himself  nearly  blind  with  one  or  both  eyes ;  or 
whilst  engaged  at  his  usual  occupation  a  dark  cloud,  or, 
as  some  haA^e  described  it,  a  red  ball  may  seem  to  appear 
before  the  affected  eye,  and  to  gradually  increase  in  size 
until  the  vision  is  either  partially  or  complete^  lost.  The 
impairment  of  sight  produced  by  the  hemorrhage  de- 
pends on  the  extent  of  the  effusion  and  the  locality  in 
which  it  has  taken  place.  One  large  retinal  vessel  may 
haA^e  given  way,  and  a  single  clot  have  formed  on  the  sur- 
face of  the  retina ;  or  there  may  be  several  small  ecchj^- 
moses  from  ruptured  retinal  or  choroidal  capillaries. 
When  it  is  from  a  large  retinal  vessel,  the  bleeding  is 
often  extensive,  and  the  blood  breaking  through  the  hya- 
loid membrane  will  be  extravasated  into  the  vitreous,  or 
it  may  force  its  way  backwards  through  the  layers  of  the 
retina,  and  form  a  clot  between  that  structure  and  the 
choroid.  The  blindness  ma}^  be  complete,  or  it  ma}^  be 
central,  so  that  the  patient  can  only  see  on  either  side  of 
the  object  he  looks  at ;  or  it  may  be  confined  to  a  portion 

18 


206  DISEASES    OF   THE    RETINA. 

of  his  field  of  vision,  according  to  the  part  of  the  retina 
pressed  on  by  the  clot. 

Ophthalmoscopic  appearances. — If  there  has  been  much 
hemorrhage,  and  the  blood  has  been  extravasated  into 
the  vitreous,  the  fundus  may  be  so  masked  that  it  will 
be  impossible  to  make  out  any  details.  The  historj-  of 
the  case,  combined  with  the  detection  of  blood  in  the 
vitreous,  will,  however,  at  once  explain  the  cause  of  the 
loss  of  sight.  When  the  hemorrhage  has  been  of  less 
extent,  a  retinal  vessel  vixa.y  be  often  seen  terminating  in 
a  lai-ge  clot.  If  there  have  been  many  small  capillary 
ecchj-moses,  these  will  be  clearly  made  out  with  the  oph- 
thalmoscope. Frequently  the  remains  of  old  blood-clots 
may  be  also  seen,  there  having  been  previous  hemor- 
rhage ;  or  markings  on  the  retina  maj^  indicate  the  site 
which  some  former  clots  occupied. 

The  prognosis  is  alwa3's  unfavorable,  for,  although 
some  improvement  may  be  gained  b}^  the  absorption  of 
the  clots,  yet,  as  the  exciting  cause  remains,  the  hemor- 
rhage is  ver}'  likely  to  recur.  When  the  blood  has  been 
extravasated,  either  into  the  vitreous,  or  formed  a  clot  be- 
tween the  retina  and  the  choroid,  the  prospect  of  regain- 
ing any  sight  is  very  slight.  In  such  cases,  as  the  blood 
is  slowly  absorbed,  the  vitreous  becomes  fluid,  the  retina 
detached,  and  the  globe  soft.  The  prognosis  is  most  fa- 
vorable when  there  is  only  one  clot,  even  though  it  be  a 
large  one,  provided  the  surrounding  retina  be  healthy, 
and  there  has  been  no  extravasation  into  the  vitreous. 

Treatment. — Inquiry  must  first  be  made  as  to  the  cause 
of  the  retinal  hemorrhage,  and  when  this  can  be  ascer- 
tained, the  endeaA-or  should  be  to  remove  it.  If  the  hem- 
orrhage is  due  to  suppressed  menstruation,  means  should 
be  taken  to  restore  the  uterine  function.  The  mist,  po- 
tassi  iodidi  (F.  14),  or  the  mist.  boraci*(F.  58)  is  often 
of  service ;  or,  if  there  is  much  anaemia,  the  mist,  ferri 


RETINITIS    PIGMENTOSA.  207 

comp.,  or  some  other  preparation  of  iron,  should  be  pre- 
scribed. The  regular  action  of  the  bowels  should  be 
maintained  by  the  pil.  aloes  et  myrrhae,  or  the  pil.  aloes 
Barbadensis. 

When  the  hemorrhage  apparently  arises  from  heart 
disease,  or  a  morbid  condition  of  the  coats  of  the  vessels, 
the  medical  man  in  attendance  must  be  guided  by  the 
symptoms  which  are  present,  and  prescribe  accordingly. 
In  all  cases  of  retinal  apoplexy,  it  is  well  to  keep  up  a 
slightly  increased  action  of  the  bowels,  and,  for  this  pur- 
pose, the  bitter  waters  of  Friedrichshall,  Pullna,  or  Kis- 
singen,  are  very  useful.  No  local  application  will  benefit 
the  eye ;  if  it  is  hot  or  painful,  a  fold  of  lint  wet  with 
cold  water  ma}^  be  laid  over  it,  or  one  or  two  leeches  may 
be  applied  to  the  temple,  and  repeated  if  they  atford  re- 
lief. 

Retinitis  pigmentosa  has  derived  its  name  from  the 
peculiar  deposition  of  the  pigment  in  the  retina  which 
characterizes  this  disease.  It  may  occur  in  persons  of  all 
ages.  Generally  the  commencement  of  this  affection  may 
be  traced  back  to  early  childhood,  but,  occasionally,  "  the 
first  symptoms  have  appeared  as  late  as  the  age  of  fift}^"* 
I  believe  that  in  most  cases  it  is  congenital,  and  in  some 
hereditary.  Both  eyes  are  usuallly  affected,  and  to  a 
similar  extent,  although  to  this  there  are  exceptions. 
Wells  mentions  a  case  in  which  only  one  eye  suffered. 
Liebreich  has  shown  that  retinitis  pigmentosa  is  frequent 
amongst  deaf-mutes,  and  also  amongst  the  offspring  of 
marriages  between  blood  relatives.  These  observations 
have  been  confirmed  b}'  Mooren  in  an  excellent  paper  on 
this  subject.f 

*  Bador  on  the  Natural  and  Morbid  Conditions  of  the  Human 
Eye,  p.  470. 

f  Ophthahnic  Review,  No.  1,  p.  4.     Translated  from  Zehendcr's 


208  DISEASES    OF   THE    RETINA. 

Symptoms. — The  characteristic  signs  of  this  disease 
are,  torpidit}^  or  diminished  sensibility  of  the  retina ;  a 
gradually  increasing  contraction  of  the  field  of  vision, 
and  a  peculiar  deposit  of  pigment  in  the  retina.  The  first 
symptom  which  generally  attracts  attention,  is  the  ina- 
bility to  walk  about  in  a  dim  light.  The  patient  suffers 
more  or  less  from  hemeralopia  or  night-blindness ;  by 
da}'  his  direct  vision  is  good,  but  after  dusk  it  is  consid- 
erably impaired.  The  contraction  of  the  field  of  vision 
increases  almost  imperceptibly  year  by  year,  but  the  di- 
rect central  sight  maj'  remain  for  a  long  period  unchanged. 
If,  however,  the  disease  continues  to  progress,  the  acute- 
ness  of  the  central  vision  becomes  first  dimmed,  and  then 
gradually'  darker,  until  ultimatel}'  the  patient  is  blind. 
The  diminution  of  the  field  is  concentric  and  equal  in  the 
two  eyes.  In  man}'  of  the  (  ases  recorded  by  Mooreu, 
commencing  cataract  in  the  posterior  pole  of  the  lens  was 
observed  in  the  later  stages  of  the  disease. 

Examined  icith  the  ophthalmoscope,  the  retina  presents 
a  ver}'  striking  appearance.  Sprinkled  in  an  apparently 
irregular  manner,  are  large  deposits  of  pigment ;  some  of 
the  spots  are  stellated,  or  of  a  spider  shaj^e  with  man}- 
small  offshoots  ;  others  look  like  mere  granules,  either 
congregated  together  in  groups,  or  scattered  about  indif- 
ferently. This  deposit  usuall}''  commences  at  the  peri- 
phery and  gradually  extends  towards  the  centre. 

When  more  carefully  examined,  the  deposition  of  pig- 
ment seems  in  places  to  foUow  the  course  of  the  retinal 
vessels,  parts  of  which  they  will  overlay.  In  manj-  cases 
the  choroid  is  also  affected,  when,  from  the  wasting  of  its 
epithelium  and  atrophy  of  its  stroma,  patches  of  it  are 
rendered  so  transparent  as  to  allow  the  white  sclerotic  to 

"  Klinische  Monatsbliitter  fiir  Augenbeilkuiidc,"  i,  p.  93, by  Zacba- 
riiih  Laurence. 


DETACHMENT    OF   THE    RETINA.  209 

shine  through  and  render  more  conspicuous  the  black 
patches  in  the  retina.  The  retinal  vessels  appear  small, 
but  this  diminution  is  said  by  Schweigger  to  be  due  to  a 
thickening  of  their  coats  and  a  consequent  lessening  of 
the  calibre,  which  restricts  the  flow  of  blood  through  them, 
and  to  this  state  of  anemia  he  attributes  the  defective 
sensibility  of  the  retina.  The  optic  nerve  has  a  pale 
aniemic  appearance,  and  when  the  disease  has  advanced 
it  exhibits  the  peculiar  dull  white  of  confirmed  atrophy. 

Treatment. — Little  if  an}'  benefit  is  to  be  derived  from 
medicine.  The  aim  must  be  to  retain  the  sight  the  pa- 
tient has,  rather  than  to  endeavor  to  recover  that  which 
has  been  lost.  The  use  of  the  ej'cs  must  be  restricted ; 
he  should  avoid  reading,  writing,  and  all  work  which  re- 
quires an  effort  of  the  accommodation.  Small  doses  of 
the  iodide  or  bromide  of  potassium,  or  of  the  perchloride 
of  mercury,  have  been  recommended,  and  may  be  tried, 
but  they  should  be  given  up  if  they  interfere  with  the 
general  health.  Spectacles  with  curved  cobalt-blue  glasses 
should  be  worn  when  in  the  open  air  or  bright  sunlight, 
as  the}'  afford  rest  to  the  eyes,  and  protection  from  the 
irritating  effects  of  wind. 

Detachment  of  the  Retina  ma}-  be  caused — 

1.  By  the  extreme  elongation  of  the  coats  of  the  eye 
which  occurs  in  severe  cases  of  myopia,  when  the  retina 
being  less  extensile  than  the  choroid  is  in  parts  separated 
from  it,  and  the  intervening  space  is  occupied  by  a  serous 
fluid. 

2.  By  a  diminution  of  the  btdk  of  the  vitreous,  so  that 
the  retina,  losing  its  due  amount  of  anterior  support, 
gradually  becomes  loosened  from  the  choroid,  and  falling 
forward  is  at  first  partially,  and  ultimately  completely  de- 
tached. This  change  may  be  induced  by  disease,  but 
most  frequently  it  is  the  result  of  a  penetrating  wound  of 

18* 


210  DISEASES    OF    THE    RETINA. 

the  eye,  which  has  been  either  accompanied  with  a  loss 
of  vitreous,  or  with  liemorrhage  into  its  substance. 

3.  By  hemorrhage  between  the  choroid  and  retina. — 
This  may  occur  in  retinitis  or  glaucoma ;  or  it  may  be 
caused  by  blows  on  the  eye.  In  most  cases  the  blood-clot 
is  ultimately  absorbed,  but  the  retina  remains  detached. 

4.  By  serous  effusion  between  the  choroid  and  retina. — 
This  may  occur  in  a  normally  shaped  eye  without  any 
stretching  of  the  posterior  coats  as  in  myopia,  or  without 
any  previous  separation  having  been  etfected  by  hemor- 
rhage. In  some  instances  it  may  possibly  be  due  to  dis- 
ease of  the  vitreous  resulting  in  a  change  of  its  structure 
and  a  lessening  of  its  bulk ;  but  in  many  cases  no  satis- 
factory cause  for  the  detachment  can  be  detected,  and  it 
is,  therefore,  ascribed  by  some  to  inflammator}^  action  of 
which  there  is  little  or  no  evidence. 

5.  By  the  presence  of  tumors  of  the  choroid.  As  the 
growth  advances  the  retina  is  carried  in  front  of  it,  and 
the  detachment  increases  with  the  progress  of  the  disease. 

Detachment  of  the  retina  ma}'  be  partial  or  complete. 
It  generally  commences  in  the  lower  region  of  the  fundus, 
and  gradually  mounts  up  towards  the  optic  nerve.  It 
usually  occurs  in  one  eye  only,  but  both  may  sufter  if  the 
separation  has  been  produced  by  causes  which  equally  af- 
fect the  two  ej'es,  as  in  cases  of  extreme  myopia.  The 
tension  of  the  globe  is  as  a  rule  slightly  diminished  when 
there  is  a  simple  detachment  with  subretinal  effusion  ; 
but  if  the  displacement  is  due  to  a  choroidal  tumor,  the 
tension  is  usually  increased. 

Syynptoms. — It  is  often  very  diflicult  to  ascertain  from 
a  patient  the  early  symptoms  of  a  displaced  retina ;  they 
have  either  passed  unnoticed,  or  in  the  lapse  of  time  have 
been  forgotten.  Some  indications  of  retinal  irritation 
are,  however,  the  general  precursors  of  the  detachment ; 
the  patient  is  frequently  troubled  for  some  weeks  pre- 


DETACHMENT    OF    THE    RETINA.  211 

viously  with  the  occasional  and  sndden  appearance  of 
bright  flashes  or  scintillations,  or  of  circles  of  fire,  &c., 
or  with  floating  mnscae  and  dimness  of  vision.  The  S3mp- 
toms  which  may  be  said  to  characterize  a  detachment  of 
the  retina  are :  Loss  of  vision  in  one  direction,  so  that  a 
portion  of  the  field  may  be  completely  wanting ;  the  pa- 
tient, with  the  aflfected  eye,  may  be  only  able  to  see  a 
portion  of  the  object  he  looks  at,  a  half  or  a  quarter  of 
it  being  quite  dark;  or  if  the  loss  is  central,  the  point  on 
which  he  directs  his  eye  is  blank,  whilst  he  can  see  on 
each  side  of  it.  He  complains  also  of  a  waving  up  and 
down  with  the  movements  of  the  head.  This  is  caused 
by  the  floating  to  and  fro  of  the  detached  portion,  and  is 
recognized  by  the  part  of  the  retina  still  in  situ.  Another 
symptom  often  mentioned  is  that  objects  appear  bent, 
twisted,  or  in  some  other  way  distorted,  and  is  no  doubt 
due  to  some  disarrangement  of  the  layers  of  a  portion  of 
the  retina  which  is  loosened,  though  not  yet  separated 
from  the  choroid. 

Examined  with  the  Ophthalmoscope The  detachment 

is  best  seen  by  direct  examination,  when,  if  the  case  is 
one  of  partial  separation  of  the  retina  from  the  choroid, 
the  detached  portion  will  appear  as  a  bluish-gray  film, 
bounded  by  a  sharp  line,  on  one  side  of  which  is  the 
bright  expanse  of  the  choroid,  shining  through  the  trans- 
parent retina  in  situ,  and  on  the  other  this  semi-opaque 
gray  web,  which  is  bulged  slightly  forwards  towards  the 
vitreous.  Tracing  the  course  of  the  retinal  vessels  from 
the  optic  nerve,  they  seem  to  be  suddenly  bent  when  they 
arrive  at  the  line  of  the  detachment.  A  partial,  or  an 
entire  displacement  of  the  retina,  if  the  separation  from 
the  choroid  is  complete,  is  easily  recognized.  It  is  when 
a  portion  of  the  retina  is  rather  loosened  or  wrinkled  than 
absolutely  detached  that  the  diagnosis  becomes  exceed- 
ingly difficult.     This  condition  is  recognized  by  a  slight 


212  DISEASES    OF   THE    RETINA. 

opacity  of  the  retina  at  one  spot,  and  b}'  noting  the  ap- 
pearance of  the  vessels,  which  appear  to  stand  out  at  one 
point  and  to  be  lost  in  the  shade  at  another,  as  they  rise 
or  fall  in  their  passage  over  the  foldings  of  the  loosened 
retina. 

The  prognosis  is  ver^-  unfavorable.  The  tendency  is 
for  the  disease  to  extend,  and  more  retina  to  become  de- 
tached until  at  last  the  e3'e  is  blind.  The  most  favor- 
able cases  are  those  in  which  there  is  a  limited  detach- 
ment, the  result  of  an  injur}',  probabl}'  a  small  effusion 
of  blood  between  the  choroid  and  retina.  A  blind  spot 
in  the  field  of  vision  will  alwajs  remain,  but  the  rest  of 
the  retina  raa,y  retain  its  functions  unimpaired.  Cases 
have  been  recorded  where  the  sub-retinal  fluid  has  disap- 
peared, and  the  retina,  having  again  fallen  back  to  its 
place,  has  still  retained  some  power  of  sight,  but  they  are 
exceptional. 

Treatment. — Detachment  of  the  retina  is  very  intract- 
able, and  generall}^  uninfluenced  by  medicines  given  for 
the  purpose  of  procuring  absorption  of  the  sub-retinal 
fluid.  A  spontaneous  cure  or  arrest  of  the  disease  has 
occasionally  occurred  from  the  accidental  laceration  of 
the  retina,  and  the  escape  of  the  fluid  into  the  vitreous. 
The  knowledge  of  this  fact  induced  Graefe  and  Bowman 
to  endeavor  to  establish  artificially  a  permanent  rent  in 
the  detached  portion  of  the  retina,  through  which  the 
fluid  could  extravasate  into  the  viti-eous.  This  they  did 
by  tearing  through  the  displaced  retina  with  either  one 
or  two  needles  introduced  through  the  sclerotic.  Yon 
Graefe  employs  a  long  cutting  needle,  "  furnished  with 
two  very  sharp  edges,  and  the  neck  of  which  fills  the 
wound,  so  as  to  leave  no  space  for  the  escape  externally 
of  the  fluid."*    Mr.  Bowman  uses  two  rather  long  needles, 

*  Graefe  on  Perforation  of  Detached  Retina.  Translated  by 
George  Henry  Rogers,  R.  L    O.  H.  Reports,  vol.  iv,  p.  222. 


EMBOLISM    OF    CENTRAL    ARTERY    OF    RETINA.       213 

which  he  introduces  through  the  sclerotic,  at  from  a 
quarter  to  half  an  inch  from  the  cornea,  and  in  the  space 
between  the  recti  tendons.  The  eye  should  be  first  ex- 
amined with  the  ophthalmoscope  to  determine  the  exact 
position  of  the  detachment.  The  operation  may  be  thus 
performed : 

The  patient  should  be  on  a  couch,  and  the  lids  being 
parted  with  a  spring  speculum,  one  needle  should  be  in- 
troduced through  the  sclerotic  at  a  point  where  it  will 
perforate  the  detached  portion  of  the  retina  at  a  promi- 
nent part.  The  second  needle  is  then  to  be  inserted  at  a 
short  distance  from  the  first,  and  so  directed  that  its 
point  shall  penetrate  the  retina  at  or  close  to  the  same 
sj^ot.  To  avoid  the  risk  of  wounding  the  lens  in  the  pas- 
sage of  the  needles,  they  should  be  thrust  through  the 
sclerotic  nearly  verticall^y.  A  rent  is  now  to  be  torn  in 
the  retina  by  separating  the  points  of  the  two  needles. 
There  is  generally  an  escape  of  the  sub-retinal  fluid  by 
the  side  of  the  needles  during  the  operation,  and  fre- 
quently in  a  sufficient  quantity  to  infiltrate  a  consider- 
able extent  of  the  subconjunctival  tissue.  The  fluid  is 
generall}^  of  a  jellowish  color,  and  when  tested  jdelds  a 
large  quantity  of  albumen.  ^ 

Embolism  of  the  Central  Artery  of  the  Retina  is 
a  cause  of  blindness  and  subsequent  atrophy  of  the  optic 
nerve.  The  loss  of  sight  is  usually  sudden  and  unaccom- 
panied by  pain.  With  the  ophthalmoscope  the  optic  disc 
appears  blanched,  the  arteries  reduced  to  the  size  of 
threads,  and  the  veins  also  much  diminished.  In  some 
of  the  cases  which  have  been  recorded,  there  was  a  loss 
of  transparency  of  the  retina  around  the  optic  nerve,  and 
in  the  region  of  the  jcllow  spot,  probably  due  to  a  slight 
serous  effusion. 

In  the  case  of  a  young  woman  under  my  care,  the  sight 


214  DISEASES    OF   THE    RETINA. 

was  lost  siuldeiil}-  and  -without  any  premoniton-  symp- 
toms a  fortnight  aftei*  her  confinement.  She  had  no  pain, 
but  she  experienced  a  sudden  sense  of  darkness  over  her 
left  e^e,  which  caused  her  to  cover  the  right  with  her 
hand,  when  she  immediateh^  discoA'ered  her  blindness. 
When  I  first  saw  her,  about  six  weeks  afterwards,  the 
optic  nerve  was  of  a  milk}^  whiteness,  and  the  retinal 
arteries  were  dwindled  to  mere  lines,  two  or  three  of 
which  were  evidently  oul}-  empty  tubes. 

The  prognosis  is  unfavorable.  Xo  treatment  is  of  any 
avail.  The  only  consolation  to  be  offered  the  patient  is, 
that  there  is  no  reason  to  suspect  that  the  other  e^'e  will 
suffer. 

TUMORS    OF    THE    RETINA. 

Glioma  of  the  Retina. — The  terrible  disease  which  ^ 
has  received  this  name  was  former^  recognized  as  me- 
dullary cancer.  There  are  two  varieties,  the  soft  or  me- 
dullary, and  the  hard  or  fibrous  glioma.  According  to 
Yirchow,  these  growths  spring  from  the  interstitial  tissue 
of  the  retina,  and  are  composed  of  lenticular,  roundish, 
spindle-shaped,  or  branched  cells,  and  of  an  intercellular 
substance  which  is  finely  fibrillated  or  granular  in  chromic 
acid  preparations.  There  is  another  form  of  this  disease 
which  he  calls  glio-sarcoma ,  from  its  presenting,  under 
the  microscope,  the  mixed  characters  of  both  glioma  and 
sarcoma. 

Glioma  generally  attacks  young  children,  affecting  first 
one  eye,  and  frequently,  after  a  short  interval,  the  other 
also.  I  had  a  little  patient  in  whom  the  disease  com- 
menced at  the  age  of  three  months,  and  was  then  visible 
to  the  mother.  When  nine  months  old  she  first  came 
under  my  care,  and  then  I  excised  the  eye.  The  child 
recovered  without  a  bad  symptom. 

Symptoms.  —  A  rapidly  increasing  loss  of  sight  in  the 


TUMORS    OF    THE    RETINA.  215 

eye^  with  more  or  less  dilatation  of  the  pupil.  If  the 
patient  is  a  child,  the  mother's  attention  is  often  first 
drawn  to  its  e^^e,  by  noticing  accidentally  a  bright  yel- 
low reflection  from  the  bottom  of  the  globe,  when  the 
light  falls  upon  the  eye  in  a  particular  direction.  Ex- 
amined with  the  ophthalmoscope,  the  tumor  will  be  seen 
occupying  a  limited  portion  of  the  retina,  and  with  blood- 
vessels on  its  surface,  which  clearly  belong  to  the  new 
growth,  and  indicate  its  great  vascularity.  In  the  imme- 
diate locality  of  the  tumor  the  retina  is  detached,  and 
this  separation  increases  with  the  advance  of  the  disease. 
Steadil}'  progressing,  the  glioma  gradually  fills  the  globe, 
displacing  the  vitreous  and  pressing  the  iris  and  lens  for- 
wards. The  cornea  first  ulcerates,  then  gives  way,  and 
the  tumor  bursting  through  the  perforation  grows  with 
an  unrestrained  activity.  It  quickly  attains  great  dimen- 
sions, its  surface  fungates  and  bleeds;  and  ultimately  the 
patient  dies,  either  from  being  worn  out  with  pain  and 
repeated  loss  of  blood,  or  from  meningitis  caused  by  an 
extension  of  the  disease  to  the  brain.  In  some  cases  the 
tumor  will  make  an  exit  for  itself  from  the  globe  by 
breaking  through  the  sclerotic  in  the  posterior  region  of 
the  eye,  but  more  frequently  it  selects  the  cornea.  In  the 
early  stages  of  the  disease  there  is  generally  no  pain ;  the 
tumor  is  as  yet  small,  it  has  room  within  the  globe  to  grow, 
and  it  presses  upon  none  of  the  ciliary  nerves.  When, 
however,  all  these  conditions  are  reversed,  and  the  tumor 
has  filled  the  globe,  and  by  its  increasing  size  distends 
to  bursting  the  coats  of  the  eye,  pressing  tightly  upon  all 
the  nervous  structures  within  them,  the  suflferings  of  the 
patient  are  extreme. 

The  prognosis  of  glioma  is  most  unfavorable.  The  dis- 
ease is  very  apt  to  recur  in  the  orbit  after  the  eye  has  been 
removed,  and  to  appear  in  the  other  eye  if  it  has  not  been 
already  affected.     The  tumor  spreads  by  infection,  which 


216  DISEASES    OF   THE    RETINA. 

travels  along  the  optic  nerve,  and,  after  death,  a  similar 
growth  is  frequently  found  in  the  brain  in  direct  com- 
munication with  the  optic  tracts. 

Treatment. — The  onl}-  chance  for  the  patient  is  an  early 
excision  of  the  globe  ;  and  should  the  two  eyes  be  affected 
I  would  excise  both,  provided  the  sight  has  been  already 
destro3^ed,  and  the  tumor  has  not  burst  through  the  ex- 
ternal coats.  Such  an  operation  would  afford  the  onl^^ 
hope  for  recovery,  whilst  at  the  same  time  it  would  save 
the  patient  much  ultimate  suflering.  On  two  occasions  I 
have  been  induced  to  remove  the  second  e3'e,  for  the  sole 
purpose  of  procuring  some  temporary'  relief  from  the  ex- 
cessive pain  induced  by  the  over-distended  globe,  and  at 
a  time  when  there  was  not  the  slightest  prospect  of  arrest- 
ing the  disease.  In  each  case  the  operation  gave  so  much 
ease,  that  under  similar  circumstances  I  should  not  hesi- 
tate to  repeat  it. 

Cysts  of  the  Retina  are  occasionally  found  In  eyes 
which  have  been  long  lost,  and  appear  to  be  due  to  degene- 
rative changes.  In  a  paper  by  M.  Iwanoff,  on  "  The  dif- 
ferent Forms  of  Inflammation  of  the  Retina,"  read  before 
tiie  Ophthalmological  Congress  at  Heidelberg,  in  Septem- 
ber, 18G4,  he  alludes  to  three  specimens,  containing  re- 
spectively one,  five,  and  seven  cysts.  The  first  example 
of  this  disease  noticed  in  this  country  was  in  an  e3'e  which 
I  removed  from  a  patient  at  the  Ophthalmic  Hospital. 
The  man  had  received  a  j)enetrating  wound  of  the  eye 
fifteen  j-ears  previously ;  after  the  accident  he  only  re- 
tained perception  of  light,  and  in  the  next  eighteen  months 
the  ej-e  became  totally  blind.  He  came  under  mv  care  in 
November,  186T.  The  lost  eye  was  ver^'  painful,  its  ten- 
sion was  increased,  and  it  was  affecting  prejudicially  the 
sound  one.  Under  these  circumstances  I  removed  the 
eye.     On  making  a  section  of  it,  the  retina  was  found 


EXUDATIVE   CHOROIDITIS.  217 

slightly  detached  from  the  choroid,  and  its  outer  aspect 
was  studded  with  cysts  of  various  sizes,  the  largest  about 
that  of  a  small  pea.  They  were  eleven  in  number,  and 
each  appeared  to  bulge  out  from  the  choroidal  aspect  of 
the  retina,  and  to  be  formed  by  the  separated  layers  of 
that  structure.  The  specimen  was  exhibited  at  the  Patho- 
logical Society,  and  in  the  Transactions,  vol.  xix,  p  362, 
will  be  found  a  full  account  of  the  case,  with  two  excellent 
woodcuts,  which  give  good  representations  of  the  two  sec- 
tions of  the  eye.  A  report  of  the  examination  of  the  C3'sts, 
made  by  Mr.  Vernon,  the  curator  at  the  hospital,  is  ap- 
pended to  the  case.  It  is  as  follows  :  "  The  cysts  appear 
to  have  been  formed  at  the  expense  of  the  outer  layers  of 
the  retina.  Their  walls  consisted  of  a  very  fine  tissue  of 
delicate  fibres,  which  contained  many  nuclei  of  their  own, 
and  which  were  closely  interlaced  with  small  nucleated 
cells,  intermingled  with  round  highly  refracting  bodies, 
the  remnants  of  the  granular  layers  of  the  retina.  To  the 
outer  walls  of  the  cysts  which  were  examined,  some  of  the 
choroidal  epithelium  was  adherent,  while  their  inner  sur- 
faces were  lined  with  squamous  epithelium.  Many  of  the 
cells  in  the  cj^st-walls  contained  fatty  granules.  With 
acetic  acid  the  fibres  forming  the  C3'st-walls  appeared  to 
consist  of  connective  tissue  without  any  elastic  element." 

DISEASES    OF    THE    CHOROID. 

Disseminated  or  Exudative  Choroiditis  is  most  fre- 
quently the  result  of  syphilis,  bpt  it  may  also  occur  in  pa- 
tients who  are  free  from  all  specific  taint,  and  from  causes 
too  indefinite  or  remote  to  be  accuratel}^  traced.  It  is 
characterized  by  disseminated  buff-colored  exudations  on 
the  surface  and  into  the  tissue  of  the  choroid.  These  ef- 
fusions are  generally  circumscribed,  and  between  them 
portions  of  unclouded  choroid  are  seen  through  the  retina. 

19 


218  DISEASES   OF   THE   CHOROID. 

As  the  disease  progresses  the  diffused  13-mph  is  absorbed, 
but  the  portion  of  the  choroid  corresponding  to  many  of 
the  patches  becomes  atropliied,  and  frequently  to  such  an 
extent  as  to  allow  the  white  sclerotic  to  shine  through  its 
attenuated  remains.  Around  these  white  patches  the  cho- 
roidal epithelium  filled  with  pigment  collects  and  encircles 
them  with  a  black  rim.  Frequently  the  retina  becomes 
secondarily  affected,  and  choroido-retinitis  is  established. 
Without,  howcA'er,  being  involved  in  the  inflammatory 
action,  portions  of  the  retina  may  be  so  pressed  on  by  the 
exuded  Ij'mph  as  to  cause  a  tem^Dorar}'  suspension  of  its 
functions,  and,  if  long  continued,  atrophy  of  its  structure. 
A  general  tui'bidit}^  of  the  vitreous  with  filmy  opacities  are 
frequently  associated  with  this  form  of  choroiditis,  and 
especially  if  it  has  a  syphilitic  origin. 

General  Symptoms. — A  gradual  failure  of  sight;  sur- 
rounding objects  appear  dark  and  confused;  occasionally 
the  field  of  vision  is  contracted,  or  parts  of  it  are  de- 
stroyed, so  that  in  certain  directions  the  patient  sees 
only  a  portion  of  the  object  he  looks  at.  The  pupil  is 
slightl}^  dilated  and  sluggish.  These  symptoms,  how- 
ever, are  common  to  other  deep-seated  affections  of  the 
ej'e,  and  it  is  onl}^  by  the  aid  of  the  ophthalmoscope  that 
the  exact  localit\^  of  the  disease  can  be  determined.  When 
thus  examined,  the  patches  of  exudation  will  be  seen 
scattei'ed  over  the  fundus  of  the  ej'c;  those  that  are  re- 
cent will  be  recognized  as  opaque  j-ellowish  spots,  whilst 
the  site  of  old  effusions  will  be  here  and  there  indicated 
by  the  glistening  white  of  the  sclerotic  shining  through 
the  atrophied  portions  of  choroid,  which  ai*e  mapped  out 
by  an  aggi'egation  of  pigment  cells.  AVhen  the  inflamma- 
tory action  is  confined  to  the  choroid,  the  retinal  vessels 
may  be  clearly  traced  throughout  their  course,  and  in 
places  mounting  over  the  effusion  which  is  beneath  them ; 
the  retina  itself  is  transparent,  and  allows  the  portions  of 


EXUDATIVE    CHOROIDITIS.  210 

bright  choroid  unobsciired  by  lymph  to  shine  through  the 
spaces  between  the  exudations ;  and  there  are  none  of  the 
hemorrhages  which  are  so  characteristic  of  most  of  the 
forms  of  retinitis.  If  the  retina  is  aifected,  as  very  fre- 
quently happens  when  this  disease  is  due  to  syphilis,  a 
diffused  haziness  of  a  part  or  whole  of  the  fundus,  with 
interruptions  in  the  course  of  the  retinal  vessels  from  in- 
flammatory effusion,  will  mask  manj^  of  the  ophthalmo- 
scopic signs  already  mentioned.  When  in  addition  to  the 
retinitis  there  is  also  a  turbidity  of  the  vitreous,  it  is 
often  impossible  to  make  out  the  details  of  the  changes 
which  may  have  taken  place,  but  sufficient  information 
will  probably  be  gained  to  form  a  diagnosis  of  the  case. 

There  are  two  forms  of  disseminated  choroiditis,  the 
syphilitic  and  the  simple. 

In  the  syphilitic  the  exudation  is  very  circumscribed, 
and  often  in  nodules  closely  resembling  those  which  are 
so  frequentl}^  seen  in  the  specific  iritis,  and  there  is  no 
tendency  for  the  effusions  to  run  together.  This  exuda- 
tive choroiditis  sometimes  occurs  as  an  extension  of  the 
iritis,  and  it  is  then  associated  with,  or  follows  closely 
upon  the  secondar}^  eruption  of  the  skin.  It  is  also  met 
with  during  the  tertiary  symptoms  of  syphilis,  but  it  is 
then  usually  complicated  with  retinitis. 

In  the  simple  form  of  disseminated  choroiditis  there  is 
no  history  of  syphilis,  the  disease  rather  resembles  the 
simple  iritis,  in.  which  the  effusion  of  lymph  is  small  in 
quantit}^  and  evenly  diffused.  The  patches  on  the  choroid 
are  less  circumscribed,  and  they  have  a  tendency  to  co- 
alesce. The  disease  is  more  chronic  and  less  amenable 
to  active  treatment. 

Treatment. — If  the  disease  is  due  to  syphilis,  the  treat- 
ment which  was  recommended  for  retinitis  syphilitica, 
page  203,  should  be  adopted,  but  with  certain  restrictions. 
When  the  disseminated  choroiditis  follows  or  is  associated 


220  DISEASES    OF   THE    CHOROID. 

with  the  secondary  skin  eruption,  the  iodide  of  potassium 
(F.  74),  with  the  mercurial  bath  (F.  2)  every  night,  or  with 
piL  riummer,  gr.  5,  every  other  night,  may  he  ordered  ; 
or,  if  the  patient  has  not  yet  been  under  the  influence  of 
mercury,  the  unguent,  hydrarg.  may  be  rubbed  into  the 
axilla  or  inner  side  of  the  thigh,  every  night,  until  the 
gums  are  slightly  affected.  If,  however,  the  disease  does 
not  occur  until  the  tertiary  period  of  syphilis,  the  prepar- 
ations of  the  hj'drarg.  perchlorid.  with  bark  (F.  80)  ;  or 
the  mist,  potassii  iodidi  cum  h^'drarg.  perchlorid.  (F.  78) 
will  be  the  most  useful. 

In  the  simple  disseminated  choroiditis,  small  doses  of 
iodide  and  bromide  of  potassium  (F.  77),  or  of  the  liq. 
hydrarg.  perchlorid.  should  be  prescribed  and  continued 
for  some  weeks,  and  at  the  same  time  a  slight  mercurial 
counter-irritation  may  be  kept  up  by  rubbing  a  little  of 
the  unguent,  hydrarg.  biniodid  (F.  105)  into  the  temple 
every  night.  If,  however,  the  patient  is  very  feeble  and 
anaemic,  the  mercurial  medicines  should  not  be  given  in- 
ternally, but  full  doses  of  quinine,  or  quinine  and  iron, 
should  be  ordered,  and  the  unguent,  hydrarg.  c.  bella- 
donna (F.  99)  rubbed  into  the  brow  and  temple  every 
night. 

ScLEBOTico-CHOROiDiTis  POSTERIOR — Posterior  StajiJiy- 
loma — is  a  prolongation  of  the  posterior  half  of  the  e3-e, 
accompanied  with  atrophy  of  the  choroid,  caused  bj^  the 
stretching  to  which  it  is  subjected  by  the  staphyloma.  It 
is  usually  found  in  all  cases  of  severe  myopia.  When  the 
disease  is  stationary^  the  mj^opia  remains  unchanged, 
and  the  patient  suflfers  no  inconvenience.  If,  however, 
it  is  progressive,  the  myopia  increases,  and  the  acuteness 
of  vision  frequently  diminishes.  The  patient  also  often 
complains  of  black  muscte,  sometimes  like  falling  soot, 
and  of  occasional  flashes  of  light,  with  other  symptoms 


SUPPUllATIVE    CHOROIDITIS.  221 

of  retinal  irritation.  If  the  eye  be  now  examined  with 
the  ophthahnoscope,  there  will  probably  be  found  changes 
in  the  choroid,  indicative  of  progressive  atrophy.  The 
white  crescent  on  the  apparent  inner  side  of  the  optic 
nerve  will  have  grown  larger,  and  its  outline  irregular ; 
and  scattered  here  and  there  will  be  white  atrophic 
patches.  Occasionally  one  or  more  of  these  spots  will 
coalesce  with  the  myopic  arc,  so  as  to  greatly  enlarge  its 
area.  Such  ej^es  are  liable  to  become  glaucomatous ; 
they  are  also  occasionally  subject  to  detachments  of  the 
retina,  and  to  small  hemorrhages  from  the  choroidal 
capillaries.  A  further  account  of  sclerotico-choroiditis 
posterior  will  be  found  in  the  article  Myopia. 

Treatment. — Absolute  rest  to  the  eyes,  and  the  direc- 
tions for  myopic  patients  given  in  the  article  Myopia, 
should  be  strictly  carried  out.  If  there  are  rapidly  pro- 
gressing changes  in  the  choroid,  small  doses  of  the  liq. 
hydrarg.  perchlorid.  (F.  80)  may  be  prescribed. 

Suppurative  Choroiditis  —  Ophthahnitis  —  Panoph- 
thalviitis — is  an  acute  suppurative  inflammation  involv- 
ing all  the  tissues  of  the  eye.  It  is  most  frequently  in- 
duced by  an  injury,  such  as  a  penetrating  wound,  or  the 
lodgement  within  the  globe  of  a  foreign  body,  or  an  abra- 
sion or  burn  of  the  cornea.  It  may  also  follow  cataract 
or  other  severe  operations  on  the  eye,  and  occasionally  it 
will  come  on  in  patients  exhausted  by  fever  or  by  long- 
continued  bad  living. 

Sympjtoms. — Great  vascularit}'^  of  the  e3'e,  with  chemo- 
sis  of  the  conjunctiva,  and  edematous  swelling  and  red- 
ness of  the  lids. 

The  aqueous  first  becomes  serous,  then  turbid  from  cor- 
puscular lymph  and  pus ;  and  these  sinking  to  the  bot- 
tom of  the  anterior  chamber,  constitute  the  state  known 
as  hypopion. 

19* 


222  DISEASES    OF    THE    CHOROID. 

The  iris  loses  its  striatiou  and  brilliancj'  from  inflam- 
matory exudation  on  its  surface  and  into  its  substance, 
and  the  pujiil  becomes  blocked  up  with  the  like  materials. 

The  cornea  becomes  dull  and  steamy,  and  pus  may  be 
infiltrated  between  its  laminae,  a  condition  recognized  as 
onyx  or  corneal  abscess,  or  an  irregular  sloughing  ulcer 
may  appear  on  its  surface. 

Such  are  the  visible  changes  which  are  rapidly  induced 
by  an  attack  of  ophthalmitis  ;  but  similar  mischief  is  also 
going  on  in  the  deeper  parts  of  the  eye. 

The  ciliary  processes  become  infiltrated  with  lymph 
and  pus,  and  matted  to  each  other. 

The  vitreous  humor  grows  turbid,  and  hmph  and  pus 
are  efl'used  within  it.  The  same  exudations  also  take 
place  on  the  sui'face  of  the  retina,  and  in  some  cases  be- 
tween the  retina  and  choroid,  and  between  the  choroid 
and  sclerotic,  all  of  which  tissues  may  be  covered  with 
morbid  deposits,  and  even  separated  the  one  from  an- 
other by  them. 

The  pain  of  ophthalmitis  is  alwaj's  very  severe.  It  is 
supra-orbital,  extending  up  the  side  of  the  head.  It  is 
around  the  orbit  and  down  the  side  of  the  nose,  and  iu 
the  eye  itself  At  first  neuralgic  in  character,  sometimes 
acute,  at  others  dull  and  aching,  but,  as  the  disease  ad- 
vances, hot  and  throbbing,  the  pain  is  usuall}'  sutficient 
to  destroy  sleep  and  to  produce  severe  constitutional 
sj^mptoms. 

The  prognosis  of  ophthalmitis  is  very  unfavorable. 
Occasionally,  under  judicious  treatment,  combined  with 
other  favorable  circumstances,  the  inflammation  may  sub- 
side, and  a  useful,  although  a  somewhat  damaged,  eye 
be  preserved.  Generallj^,  however,  the  activitj^  of  the 
disease  continues  unabated,  and  does  not  expend  itself 
until  all  the  tissues  of  the  eye  are  involved  in  one  general 
suppuration.      The  cornea  then  gives  way,  or  the  pus 


SUPPURATIVE    CHOROIDITIS.  223 

makes  an  exit  foi*  itself  througla  the  sclerotic  between 
the  insertions  of  two  of  the  recti  tendons. 

Treatment. — The  eye  shonld  be  frequently  fomented 
with  the  fotus  belladonnte  (F.  8),  or  with  the  decoction 
of  poppy-heads.  A  solution  of  atropine,  gr.  1  ad  aquae 
^1,  should  be  dropped  into  the  eye  twice  or  three  times 
a  day ;  but  it  should  be  discontinued,  as  useless,  when 
suppuration  has  actually  set  in.  The  patient  should  be 
kept  in  a  darkened  room,  and  all  use  of  the  eyes  should 
be  prohibited.  The  bowels  should  be  acted  on  at  the 
commencement  of  the  attack,  and  if  the  patient  is  rest- 
less, sleep  should  be  produced,  and  the  pain  relieved  by 
opium.  In  these  cases  opium  is  usually  of  the  greatest 
service.  It  assuages  the  pain,  tranquillizes  the  patient, 
and  places  him  in  a  more  favorable  condition  for  re- 
covery. Whilst  there  is  hot  skin  and  thirst,  salines  and 
diaphoretics  should  be  prescribed ;  but  these  must  soon 
give  place  to  quinine  or  bark,  with  the  mineral  acids. 
The  strength  of  the  patient  should  be  maintained  by  a 
liberal  strong  beef-tea  diet,  with  a  moderate  allowance  of 
wine  or  brandy.  But  if  the  inflammation  goes  on,  and 
the  cornea  becomes  ulcerated,  or  infiltrated  with  pus;  or 
if  there  is  hypopion,  w-ith  the  eye  painfnl  and  the  auterior 
chamber  deepened  by  the  increased  secretion  of  the  aque- 
ous, tapping  the  anterior  chamber  with  a  broad  needle, 
will  sometimes  afford  A^ery  considerable  relief,  and  mate- 
rially benefit  the  eye.  The  activity  of  the  disease  is  fre- 
quently sensibly  diminished  after  one  such  operation.  It 
is  not,  however,  a  proceeding  which  should  be  undertaken 
rashl}'^,  as,  when  it  fails  to  do  good,  it  often  seems  to  irri- 
tate the  eye  and  increase  the  urgency  of  the  symptoms. 
In  some  bad  cases  of  ophthalmitis  w'hich  have  been  under 
my  observation,  I  am  satisfied  that  the  ultimate  destruc- 
tion of  the  e3'e  has  been  hastened  by  an  injudicious  para- 
centesis of  the  cornea.     When  the  operation  gives  ease. 


224  DISEASES    OF   THE   CHOROID. 

it  may  be  repeated  at  interA'als  of  twentj'-four  or  thirty- 
six  lioiirs,  if  the  i)aiii  and  acute  s^^mptoms  recur;  but, 
if  after  once  tapjjing  the  anterior  chamber,  the  pain  in 
the  eye  is  increased,  it  should  not  again  be  attempted. 

If  all  treatment  has  failed  to  arrest  the  progress  of  the 
disease,  and  suj^puration  of  the  globe  has  actually  set  in, 
I  would  advise  the  eye  to  be  excised.  The  patient  will 
thus  be  quickl}^  restored  to  health,  and  be  spared  much 
suffering.  In  my  own  practice  I  have  never  had  any 
unfavorable  s^'mptoms  follow  the  excision  of  a  suppurat- 
ing eye. 

Deposits  of  Bone  on  the  Choroid  are  frequently 
found  in  eyes  which  have  been  long  lost.  The  bony 
matter  is  on  the  anterior  surface  of  the  choroid,  between 
it  and  the  retina,  which  is  always  detached,  and  usually 
coarcted.  In  some  cases  a  mere  ossific  film  is  found 
lying  on  the  choroid,  whilst  in  others  there  is  a  thick 
bony  cup,  sufficient  in  size  to  occupy  nearly  the  entire 
stump. 

It  seems  very  probable  that  the  formation  of  these  bony 
plates  is  due  to  an  inflammatory  exudation  of  l3'mph  on 
the  surface  of  the  choroid,  which  after  a  lapse  of  time  be- 
comes organized  and  converted  into  fibrous  tissue.  This 
afterwards  undergoes  a  further  change ;  osseous  granules 
are  deposited  within  it,  and  it  becomes  bone,  having  all 
the  characters,  both  anatomical  and  chemical,  which  dis- 
tinguish this  tissue  in  other  parts  of  the  body.  The  cup 
of  bone  is  usually  perforated  near  its  centre  bj'  a  small 
canal,  through  which  passes  a  band  of  the  atrophied 
retina  back  to  the  optic  nerve. 

Whilst  bone  is  thus  being  developed  in  the  fundus  of 
the  eye,  earthy  salts,  such  as  the  phosphate  or  carbonate 
of  lime,  are  frequentl}-  at  the  same  time  being  deposited 
in  the  lens,  if  there  is  one,  and  between  the  laminae  of 


HEMORRHAGE   FROM    THE    CHOROID.  225 

the  cornea,  or,  if  that  has  been  destroj'ed,  in  the  cica- 
tricial tissue  which  has  replaced  it. 

In  a  report  of  a  specimen  of  ''bone  from  the  inner  sur- 
face of  the  choroid,"  by  Mr.  Hulke,  in  the  Pathological 
Transactions,  vol.  viii,  page  320,  he  has  given  the  draw- 
ings of  the  microscopical  appearances  of  the  sections  he 
examined.  He  found  in  them  all  the  elements  of  true 
bone — a  complete  system  of  vascular  canals,  with  lacunae 
and  canaliculi.  In  the  mere  scales  of  bone  which  he  has 
since  examined,  he  has  told  me  that  he  has  been  unable 
to  detect  any  vascular  canals,  but  in  all  he  has  seen  the 
lacuna?  and  canaliculi.  This  is  probably  simply  due  to 
the  fact  that  such  delicate  films  of  bone  were  too  thin  to 
admit  of  vascular  canals. 

Tubercles  in  the  Choroid  may  be  frequently  found 
in  patients  who  are  suffering  from  acute  tuberculosis. 
In  the  cases  which  have  been  recorded  they  produced  no 
defect  of  sight.  With  the  ophthalmoscope  they  may  be 
recognized  as  "  small  circular  circumscribed  spots  of  a 
pale  rose-color,  or  grayish-white  tint,  and  vary  in  size 
from  ^  to  2.5  mm.  The}'  are  chiefly  situated  in  the  vicin- 
ity of  the  optic  disc,  but  may  extend  occasionally  to  a 
considerable  distance  from  it."  * 

Hemorrhage  from  the  Choroid  may  occur  from  in- 
jury (see  next  section.  Injuries  of  the  Choroid),  or  it 
may  be  occasioned  by  disease,  as  in  glaucoma,  sclerotico- 
choroiditis  posterior,  or  retinal  apoplexy.  See  the  arti- 
cles on  these  subjects.  It  may  also  be  produced  by 
prolonged  and  excessive  strain  of  the  eyes  at  close  work, 
and  especially  if  during  its  continuance  the  head  has  to 
be  maintained  in  a  stooping  position. 

*  Soelberg  Wells's  Treatise  on  the  Eye,  p.  440. 


226  DISEASES   OF   THE    CnOROID. 

The  Treotment  must  depend  on  the  exciting  cause 
of  the  hemorrhage :  see  articles  Glaucoma,  Sclerotico- 
Choroiditis  Posterior,  and  Retinal  Apoplexy. 

INJURIES    OF    THE    CHOROID. 

Injuries  or  the  Choroid  are  usually-  followed  by  im- 
mediate hemorrhage  which  always  seriously  affects,  and 
often  completel}^  destroj'S  sight.  A  blow  on  the  e^-e  ma}^ 
cause  a  rent  in  the  choroid,  either  with,  or  without  rupture 
of  the  external  coats ;  or  the  choroid  may  be  lacerated  by 
a  penetrating  wound  through  the  sclerotic.  Hemorrhage 
at  once  takes  place  from  the  torn  choroidal  vessels,  and  ac- 
cording to  the  site  and  severity  of  the  injurA^  the  blood  may 
be  extravasated : 

1.  Between  the  choroid  and  retina. 

2.  Between  the  choroid  and  sclerotic. 

3.  Into  the  vitreous  humor. 

1.  Hemori'hage  between  the  choroid  and  retina  is  gene- 
rally caused  by  blows  on  the  ej^e,  and  may  occur  either 
with  or  vnthout  rupture  of  the  external  coats.  The  blood 
is  poured  out  from  the  anterior  surface  of  the  choroid,  and 
a  clot  is  formed  between  that  structure  and  the  retina. 
When  the  clot  is  small,  it  may  be  absorbed,  and  the  e3'e 
ma}^  regain  useful  vision,  but  there  will  alwavs  remain  a 
blind  spot  corresponding  with  the  portion  of  retina  which 
had  been  detached.  If  the  hemorrhage  is  severe,  there 
will  be  necessarily  an  extensive  separation  of  the  retina, 
and  the  ej^e  for  all  useful  purposes  will  be  destroyed. 

2.  Hemorrhage  between  the  choroid  and  sclerotic^  un- 
complicated with  hemorrhage  in  any  other  part  of  the  eye, 
is  most  commonl}^  produced  by  an  escape  of  the  lens  and 
a  sudden  loss  of  vitreous  through  a  wound  in  an  unhealthy 
eye  ;  thus  withdrawing  unexpectedly  the  support  which 
the  choroid  and  retina  had  derived  from  these  structures, 


HEMORRHAGE  FROM  THE  CHOROID.       227 

when,  in  their  entirety,  they  occupied  their  normal  posi- 
tion within  the  globe. 

In  a  healthy  eye,  the  lens  and  a  large  amount  of  vitreous 
humor  may  be  lost  through  a  wound  of  its  external  coats, 
without  exerting  any  very  unfavorable  influence  on  the 
retina  or  the  choroidal  vessels  ;  but  in  an  unsound  eye,  a 
similar  loss  would  probably  produce  hemorrhage  between 
the  choroid  and  sclerotic.  From  chronic  disease,  and  the 
repeated  increased  vascularity  of  the  eye  consequent  on 
it,  the  tonicity  of  the  choroidal  vessels  is  diminished,  and 
their  walls,  either  weakened  by  recurrent  distension  or 
from  some  deprivation  of  the  nervous  influence  of  the 
S3'mpathetic  filaments  which  preside  over  them,  become 
easily,  and  on  the  slightest  irritation,  undulj"  dilated.  In 
such  e3'es,  the  loss  of  the  lens,  or  of  a  portion  of  the 
vitreous,  by  diminishing  the  pressure  on  the  choroidal 
vessels  counter  to  the  force  of  the  impulse  of  the  blood 
within  them,  will  induce  a  sudden  distension  and  yielding 
of  their  coats,  which  frequently  lead  to  rupture,  and  hem- 
orrhage between  the  choroid  and  sclerotic.  It  is  this  form 
of  hemorrhage  which  occasionally  occurs  after  an  opera- 
tion for  the  removal  of  a  cataractous  lens  from  an  unsound 
eye.  Indeed  it  is  almost  certain  to  happen  if  there  be  an 
increased  or  glaucomatous  tension  of  the  eye  at  the  time 
of  operating.  In  such  cases,  the  hemorrhage  takes  place 
from  the  posterior  surface  of  the  choroid,  detaching  some- 
times partially,  but  generally  completely,  the  choroid  from 
the  sclerotic,  and  forming  a  large  blood-clot,  it  pushes  in 
front  of  it  the  choroid  and  retina,  aud  extrudes  more  or 
less  of  the  vitreous  from  the  eye. 

When  hemorrhage  between  the  choroid  and  sclerotic  is 
occasioned  by  blows  on  the  eye,  the  bleeding  is  seldom 
confined  to  the  space  between  the  choroid  aud  retina,  but 
takes  place  also  in  other  parts  of  the  eye,  and  blood  is 


228  DISEASES    OF   THE    CHOROID. 

often  found  also  on  the  retina,  between  it  and  the  choroid, 
and  in  the  vitreous. 

3.  Hemorrhage  into  the  vitreous  raaj  occur  from  an  in- 
jury of  the  choroid.  If  the  hemorrhage  is  severe,  the 
blood  frequentl)'  bursts  through  the  retina  and  hyaloid 
membrane,  and  extravasates  itself  into  the  vitreous  body. 
For  a  further  account  of  hemorrhage  into  the  vitreous, 
see  the  article  in  the  chapter  on  the  Diseases  of  the 
YiTREOUS,  page  148. 

The  prognosis  of  choroidal  hemorrhage  is  always  un- 
favorable. It  is  only  when  the  bleeding  has  been  slight 
and  limited  to  a  small  surface,  that  even  a  hope  can  be 
held  out  that  a  certain  amount  of  useful  sight  will  be  re- 
tained. If  in  such  a  case  the  patient  progi'esses  favor- 
abh',  he  will  probably  recover  with  some  valuable  sight, 
but  he  will  not  regain  that  which  was  destroyed  by  the 
blood-clot :  one  blind  spot  in  his  field  of  vision  will  indi- 
cate the  extent  of  retina  which  has  been  detached,  and  the 
loss  the  eye  has  sustained.  When  there  is  extensive  cho- 
roidal hemorrhage,  the  eye  for  all  visual  purposes  is  lost ; 
no  matter  whether  the  blood  is  effused  into  the  vitreous, 
or  between  the  retina  and  choroid,  or  the  choroid  and 
sclerotic.  If  the  eye  does  not  suppurate  (and  as  a  rule 
it  does  not  do  so  if  the  external  coats  are  entire),  it  grad- 
ually under  treatment  subsides  into  a  quiet  state,  becomes 
soft,  and  somewhat  smaller  than  the  other. 

Treatment. — Immediately  after  the  injury  a  leech  or 
two  raa}^  be  applied  to  the  temple  with  the  hope  of  pre- 
A'enting  au}^  undue  inflammator}-  action ;  and  a  fold  of 
lint  or  linen,  dipped  in  cold  or  iced-water,  should  be 
placed  over  the  eye,  and  wetted  as  often  as  it  becomes 
dr^^  and  hot.  Two  or  three  drops  of  a  solution  of  the 
sulphate  of  atropia,  gr.  1  ad  aqua?  5  1,  should  be  dropped 
into  the  eye  twice  a  day.  It  will  exert  a  sedative  influ- 
ence, and  also  act  beneficially  on  the  pupil  if  any  active 


TUMORS    OF    THE    CHOROID.  229 

inflammation  comes  on.  Complete  rest  should  be  given 
to  the  sound  eye  by  abstaining  from  all  work,  and  the 
exclusion  of  strong  light  from  the  room.  There  are  no 
special  applications  or  medicines  which  can  be  given 
with  the  view  of  favoring  absorption  of  the  blood  which 
has  been  effused. 


TUMORS    OF    THE    CHOROID. 

Tumors  of  the  Choroid  are  of  two  kinds,  the  sarcom- 
atous and  the  cancerous.  In  their  first  appearance,  sub- 
sequent growth,  and  symptoms,  they  closely  resemble 
each  other ;  it  is  only  by  a  microscopic  examination  that 
their  true  natures  can  be  correctlj^  determined.  A  small 
nodide  first  appears  on  the  choroid,  which  detaches  the 
portion  of  retina  with  which  it  is  in  contact,  and  loosens 
also  that  which  surrounds  it.  As  it  grows  it  pushes  for- 
wards the  retina,  displaces  the  vitreous,  and  presses  the 
lens  and  iris  towards  the  cornea.  Frequently  the  globe 
loses  its  normal  shape,  and  dark  bulgings  will  be  seen  in 
the  ciliary  region.  The  cornea  grows  dull,  then  ulcerates, 
and  through  the  opening  the  tumor  crops  out ;  or  else  it 
makes  an  exit  for  itself  posteriorly,  and  bursting  though 
the  sclerotic  it  extends  itself  into  the  orbit.  Having  es- 
caped from  within  the  globe,  it  seems  as  if  it  had  acquired 
new  vitality,  and  grows  with  an  increased  vigor.  After 
a  time  its  surface  ulcerates  and  bleeds,  and  it  assumes  an 
appearance  which  has  given  to  it  the  name  of  "  fungus 
hijematodes."  The  attacks  of  hemorrhage  increase  in 
frequency  with  the  advance  of  the  disease,  until  the  pa- 
tient at  length  sinks,  worn  out  with  pain  and  loss  of  blood. 
Such  is  the  history  of  a  case  which  has  been  allowed  to 
proceed  to  its  termination  unchecked  by  surgical  treat- 
ment, but  fortunately  these  examples  are  now  rare.  It 
should   be   remembered,   that,    during   the   progress   of 

20 


230  DISEASES    OF    THE    CHOROID. 

growth  of  an  intraocular  tumor,  an  increased  tension  of 
the  globe  frequentl^^  occurs,  and  that  from  overlooking 
the  cause  of  these  glaucomatous  symptoms,  mistakes 
have  occasionally  been  made  b}'  treating  such  cases  with 
iridectomy. 

Tlie  sarcoma  of  the  choroid  is  a  recurrent  growth,  and 
in  this  respect  resembles  cancer,  but  it  seldom  produces 
secondary  deposits  in  other  organs.  It  grows  from  the 
connective  tissue  of  the  choroid,  and  as  it  fills  the  globe 
it  does  not  infiltrate  and  become  incorporated  with  the 
other  structures  of  the  eye  as  in  true  cancer.  Examined 
with  the  microscope,  it  has  a  soft  fibrillated  matrix,  in 
which  are  imbedded  oval,  spindle-shaped,  and  caudate 
cells,  each  containing  a  nucleus  and  nucleolus.  When 
the  sarcoma  is  more  or  less  colored  with  pigment,  it  is 
termed  melanotic  sarcoma.  In  most  cases  there  is  some 
pigment  disposed  irregularly  throughout  the  tumor. 

The  Aledullary  Cancer — encejyhaloid — medullary  sar- 
coma— are  the  names  which  are  commonly  applied  to  this 
disease ;  it  is  also  known  as  the  soft  and  the  acute  cancer. 
It  is  characterized  bj'^  its  rapid  growth  and  its  tendency 
to  fungate  as  soon  as  it  has  burst  from  its  confinement 
within  the  globe.  It  affects  the  neighboring  h'mphatics 
and  produces  deposits  in  the  brain,  the  lungs,  the  liver, 
and  other  viscera.  It  is  very  vascular,  soft,  and  pulpy, 
like  brain-matter,  and  on  section  it  often  exhibits  many 
small  hemorrhagic  spots  from  divided  vessels,  which 
make  its  resemblance  to  cerebral  substance  more  striking. 
Under  the  microscope,  it  is  found  to  consist  of  a  stroma 
of  delicate  fibres  inclosing  between  its  alveoli  large  nu- 
cleated corpuscles  of  various  shapes — mostl}'  roundish 
and  fusiform. 

Melanotic  cancer  is  the  same  disease  as  the  medullary, 
the  only  difference  being  the  addition  of  the  black  pig- 
ment which  is  scattered  in  varying  quantities  throughout 


OPTIC    NEURITIS.  231 

its  structure.  I  have,  ou  two  or  three  occasions,  seen  the 
identity  of  the  two  affections  well  illustrated  by  the 
changes  which  have  occurred  in  the  growth  of  the  tumor. 
Whilst  confined  within  the  globe,  the  growth  in  each  case 
was  deeply  colored  with  pigment,  so  as  to  be  in  parts  ab- 
solutely black ;  but  having  burst  through  the  sclerotic 
posteriorly,  it  grew  with  an  increased  rapidity,  and  the 
extraocular  portion  was  white.  The  tumor  external  to 
the  globe  was  the  same  growth  and  continuance  with 
that  which  was  within  the  eye ;  both  were  medullarj'^,  but 
the  addition  of  pigment  made  that  within  the  globe  me- 
lanotic. 

The  prognosis  of  choroidal  tumors  is  generally  unfa- 
vorable. The  best  chance  is  afforded  the  jjatient  when 
the  disease  is  detected  early,  and  the  eye  removed  before 
the  tumor  has  attained  a  large  size.  It  is  of  the  greatest 
importance  that  the  eye  should  be  excised  before  the  tu- 
mor has  burst  through  the  external  coats,  as,  when  the 
disease  has  reached  this  stage,  there  is  the  probability 
that  the  neighboring  tissues  have  become  infected  by  it. 
For  the  detection  of  choroidal  tumors  the  ophthalmoscope 
is  invaluable,  as  with  it  the  existence  of  a  morbid  growth 
ma^^  be  determined,  when  the  only  sj-mptom  is  a  loss  of 
sight  in  a  portion  of  the  field  of  vision. 

Treatment. — Excision  of  the  eye.  If  the  tumor  has 
made  its  wa}^  through  the  sclerotic,  the  chloride  of  zinc 
paste  (F.  7)  should  be  applied  to  the  tissues  in  the  orbit, 
in  the  manner  recommended  in  the  section  Treatment 
OF  Orbital  Tumors. 

DISEASES    OP    THE    OPTIC    NERVE. 

Optic   Neuritis  —  Neuro-retinitis There   are   two 

forms  of  neuritis : 

In  the  first,  the  inflammation  is  confined  to  the  optic 


232  DISEASES    OF    THE    OPTIC    NERVE. 

nerve.  It  is  then  the  result  of  disease  be3'ond  the  eye, 
and  may  be  caused  by  tumors  in  the  brain  or  in  the  orbit, 
or  by  an  intracranial  syphilitic  node,  or  by  meningitis, 
hydrocephalus,  or  any  other  affection  within  the  skull 
which  produces  pressure  on  the  nerve,  or  impedes  the  re- 
turn of  blood  through  the  opthalmic  vein  to  the  cavernous 
sinus.  To  this  form  of  neuritis  the  term  descending  has 
been  applied,  because  the  symptoms  descend  along  the 
trunk  of  the  optic  nerve  to  the  papilla  within  the  eye. 

In  the  second  form  of  neuritis  the  inflammation  is  not 
limited  to  the  optic  nerve,  but  it  includes  also  the  retina, 
and  may,  therefore,  be  rightly  termed  neuro-retinitis.  It 
may  be  induced  by  syphilis,  by  derangements  of  the 
functions  of  the  uterus,  or  by  fever,  or  any  other  ex- 
hausting disease. 

1.  Symptoms  of  descending  Optic  Neuritis.  —  During 
the  acute  or  early  stage,  there  is  an  increased  redness  of 
the  optic  disc,  but  this  gradually  subsides,  and  it  as- 
sumes a  grayish-white  color,  with  a  peculiar  "  woolly  " 
look,  "  much  as  if  cotton-wool  had  been  carded  until  all 
its  fibrils  radiated  outwards  from  a  centre."*  The  state 
of  the  optic  papilla  presents  a  characteristic  appearance 
which  has  been  termed  the  engorged  papiUa.  It  is  swollen 
and  prominent,  sometimes  bulging  forward  to  such  an 
extent  as  to  be  easily  recognized  by  direct  examination 
with  the  ophthalmoscope.  The  outline  of  the  disc  is  ir- 
regular, confused,  or  lost ;  the  arteries  are  small  and 
thready ;  the  veins  large,  dark-colored,  and  often  tor- 
tuous, and  portions  of  the  vessels  in  their  course  oa' er  the 
papilla  are  obscured  by  exudation.  Occasionally  there  arc 
small  hemorrhagic  spots  on  the  disc  and  in  the  adjacent 
retina,  which  is  often  of  a  dull  and  whitish  color  from 

*  Hutc'hinson  on  Intliimniation  of  the  Optic  Nerve.  Koyal 
London  Ophthalmic  llospital  lieports,  vol.  v,  p.  'J8. 


OPTIC   NEURITIS.  233 

inllanimatoiy  eftusions,  whilst  the  rest  of  the  retina  re- 
mains perfectly  transparent.  There  is  a  steady  diminu- 
tion of  the  acuity  of  vision,  often  accompanied  with  a 
contraction  or  partial  loss  of  the  visual  field.  The  pupil 
is  rather  dilated  and  sluggish.  The  patient  has  no  pain 
in  the  eye,  nor  are  there  any  external  manifestations  to 
account  for  the  increasing  loss  of  sight.  Both  e3'es  are 
generally  affected,  and  the  disease  usually  symmetrical ; 
but  one  eye  may  be  attacked  a  little  in  advance  of  the 
other,  or  the  impairment  of  sight  may  be  greater  in  one 
eye  than  in  the  other.  After  a  variable  time  all  the 
l^rominent  ophthalmoscopic  symptoms  of  neuritis  sub- 
side ;  the  morbid  etfusions  are  absorbed,  the  disc  be- 
comes flattened  and  of  a  creamy  white,  and  the  arteries 
are  reduced  to  mere  threads,  but  for  a  long  time  the 
veins  continue  large  and  tortuous. 

With  all  these  changes  there  is  a  steady  dimiuution  of 
sight,  until  ultimately  it  is  completely  lost  or  reduced  to 
a  mere  perception  of  large  objects.  A  very  interesting 
paper  on  "  Defects  of  Sight  in  Diseases  of  the  Nervous 
System,"  has  been  published  by  Dr.  J.  Hughlings  Jack- 
son, in  the  Royal  London  Ophthalmic  Hospital  Reports, 
vol.  iv,  p.  389,  in  which  he  shows  the  frequency  of  optic 
neuritis  in  diseases  of  the  brain,  and  to  which  I  would 
refer  the  reader. 

The  constitutional  symptoms  all  point  to  disease  within 
the  head,  and  to  an  interference  with  the  healthy  cere- 
bral circulation.  There  is  frequently  severe  headache 
and  giddiness,  both  of  which  may  be  either  constant  or 
intermittent,  or  there  may  be  loss  of  smell  or  defect  of 
hearing,  or  occasional  epileptic  convulsions,  or  palsy  of 
one  or  more  of  the  ocular  nerves,  or  a  loss  of  the  proper 
co-ordinating  power  over  the  muscles  of  the  extremities. 

2.    Symptoms  of  Neuro-retinitis The   optic   disc   is 

clouded,  its  outline  is  indistinct  or  lost,  and  the  vessels, 

20* 


234  DISEASES    OF   THE    OPTIC    NERVE. 

as  they  pass  over  its  surface,  are  more  or  less  obscured  ; 
but  there  is  not  the  venous  distension  or  the  engorgemeut 
of  the  papilla  which  characterize  the  pure  neuritis  descen- 
dens.  The  great  point  of  distinction,  however,  between 
neuritis  and  neuro-retinitis  is,  that  in  the  one  the  retina 
is  extensively  involved,  whilst  in  the  other  it  is  either  not 
at  all  affected,  or  only  for  a  short  distance  immediately 
surrounding  the  disc. 

In  neuro-retinitis  the  whole  surface  of  the  retina  seems 
obscured  by  a  diffused  haze,  which  renders  all  the  minute 
A^essels  indistinct,  and  gives  a  peculiar  and  characteristic 
washed-out  appearance  to  the  fundus.  There  is  also  an 
absence  of  the  head  symptoms,  which  were  noticed  as 
being  generall}^  present  in  neuritis.  In  neuro-retinitis 
the  disease  is  often  confined  to  the  one  e3'e,  whereas,  in 
neuritis  descendens,  both  e^^es  are  generaUy  affected. 

The  i^rognosis  of  neuritis  dependent  on  cerebral  causes 
is  very  unfavorable.  The  disease  generally  resists  all 
treatment,  and  ends  in  atroph}'  of  the  optic  nerve  and 
blindness.  The  prognosis  of  neuro-retinitis,  although 
uufavoi-able,  is  yet  more  hopeful  than  that  of  neuritis, 
and  especially  if  some  blood-poisoning,  such  as  syphilis, 
can  be  traced  as  the  probable  cause  of  the  disease. 

Treatment. — For  neuritia  desce)idenst\xe  treatment  must 
be  guided  by  the  existing  s3'mptoms,  which  generally  point 
to  mischief  within  the  head.  No  special  remedies,  how- 
ever, can  be  advised  for  their  relief,  as  the  causes  which 
produce  them  are  both  too  numerous  and  obscure.  Large 
doses  of  the  bromide  of  potassium  will  sometimes  do  good ; 
or,  if  there  is  any  syphilitic  taint,  the  iodide  of  potassium 
ma}^  be  also  tried. 

In  neuro-retinitis,  care  must  be  taken  to  ascertain  the 
source  of  the  disease,  as  it  may  be  due  to  many  causes. 
When  it  can  be  ascribed  to  syphilis,  the  mist,  potass,  iodid. 
(F.  74)  may  be  given  during  the  day,  and  pil.  Plummer 


NEURO-RETINITIS.  235 

gr.  5  every  other  night ;  or  the  mist,  potassii  iodidi  cum 
hydrarg.  perchlorid.  (F.  78)  iLnay  be  prescribed.  If  the 
l)atient  is  feeble,  the  unguent,  hydrarg.  cum  belladonna 
(F.  99)  may  be  rubbed  into  the  temple  night  and  morn- 
ing, and  the  mist.  quinjE  (F.  64)  be  taken  during  the  day. 

When  the  disease  is  apparently  due  to  suppressed  men- 
struation, every  endeavor  should  be  used  to  restore  the 
uterine  functions.  In  some  cases  I  have  had  excellent 
^sults  from  the  iodide  of  potassium  given  in  10  gr.  doses 
twice  a  day  in  water.  It  has  then  acted  as  a  powerful 
emmenagogue.  I  must,  however,  confess  that  this  medi- 
cine has  occasionally  failed  to  do  good,  or  its  administra- 
tion has  been  attended  with  only  a  partial  success.  No- 
tice should  be  taken  whether  the  ameuorrha^a  is  due  to 
antemia  or  congestion.  If  the  former,  tonics  of  quinine 
and  iron,  or  the  mist,  ferri  perchlorid.  cum  tinct.  ergotoe 
(F.  12)  may  be  ordered,  but  at  the  same  time  some  aloetic 
pill  should  be  prescribed  to  insure  the  regular  daily  action 
of  the  bowels.  If  the  suppression  is  due  to  congestion,  the 
bowels  should  be  freely  acted  on  by  a  brisk  purgative.  In 
some  cases  small  doses  of  podophyllin  given  every  other 
or  third  night,  do  good.  During  the  day,  the  iodide  and 
bromide  of  potassium,  in  a  bitter  infusion,  or  the  mist, 
boracis  (F.  58)  may  be  given.  When  the  sight  is  rapidly 
failing,  and  there  is  much  pain  in  the  head,  I  have  known 
the  inunction  of  the  unguent,  hydrarg.,  night  and  morn- 
ing, so  as  to  get  the  patient  quickly  under  its  influence, 
productive  of  great  good.  As  soon  as  the  gums  are 
spongy,  the  frequency  of  the  rubbing  in  must  be  dimin- 
ished, but  a  slight  mercurial  action  should  be  kept  up  for 
two  or  three  weeks. 

In  cases  of  neuro-retinitis  dependent  on  or  associated 
with  great  debility,  such  as  after  fever,  or  diphtheria,  or 
from  over-lactation,  the  mineral  acids,  with  cinchona,  or 
some  of  the  preparations  of  iron,  are  most  likely  to  do 


236  DISEASES    OF    THE    OPTIC    NERVE. 

good.  A  slight  mercurial  counter-irritation  may  be  also 
kei^t  up  on  the  temple  of  the  affected  eye,  b}'  rubbing  in 
every  night,  a  little  of  the  unguent,  hj-drarg.  biniodid. 
(F.  105);  or  by  applying  small  blisters  about  the  size  of 
a  shilling,  from  time  to  time,  and  afterwards  dressing  the 
vesicated  surfaces  with  the  unguent,  h^'drarg. 

Atrophy  of  the  Optic  Xerve — white  atrophy — may 
be  caused  by  disease  of  the  brain  or  medulla  oblongata 
or  it  ma}'  be  the  unfortunate  termination  of  some  deep- 
seated  inflammation  of  the  eye. 

Atrophy  of  the  optic  nerve  may  therefore  be  considered 
under  two  headings : 

1.  That  which  proceeds  from  disease  beyond  the  eye. 

2.  That  which  arises  from  disease  icifhin  the  e3-e. 

1.  Atrophy  of  the  Optic  Nerve  from  Disease  beyond  the 
Eye. — This  form  is  mostly  occasioned  b}^  cerebral  or  cere- 
bro-spinal  disease,  or  by  tumors  within  the  orbit.  Neu- 
ritis of  both  eyes  ma}'  be  thus  induced,  and  atrophj^  of 
the  optic  nerves  may  follow  as  a  consequence.  Atrophy 
ma}',  however,  come  on  without  neuritis,  dependent,  no 
doubt,  upon  cerebral  causes,  but  which  are  often  too  ob- 
scure to  be  diagnosed.  It  is  to  atrophy  of  the  nerve, 
arising  from  disease  beyond  the  eye,  that  the  term  "white 
atrophy"  is  properly  applied.  In  the  other  forms  of 
atrophy  the  papilla  is  also  grayish-white  or  white,  and 
especially  in  their  most  adAanced  stages ;  but  the  charac- 
teristic signs  of  white  atrophy  of  the  optic  nerve  are  best 
found  in  cases  arising  from  cerebral  disease.  See  article 
Amaurosis,  page  238. 

Ophthalmoscopic  Apjpearances. — When  the  disease  is 
fully  advanced,  the  optic  disc  looks  large,  flat,  and  of  a 
bluish  or  pearly  whiteness.  The  retinal  vessels  are  gen- 
erally small ;  the  arteries  often  appear  as  mere  threads. 


1%         ATROPHY    OF    THE    OPTIC    NERVE.  237 

but  in  some  cases,  and  especially  in  those  which  proceed 
from  neuritis,  the  veins  are  large  and  distended.  The 
small  bloodvessels,  which  are  usualh'  seen  on  the  disc, 
have  shrunken  from  view,  and  the  surface  of  the  nerve  is 
blanched  and  bloodless.  There  is  frequently  an  excava- 
tion of  the  optic  nerve,  not  from  any  increased  tension 
of  the  eye,  but  from  a  shrinking  from  atroph}^  of  the  ner- 
vous elements,  and  a  falling  in  of  the  central  portion  of 
the  papilla.  The  peculiarities  of  this  '■''atrophic  cup^^  are, 
that  it  is  a  shallow  excavation,  shelving  from  the  margin 
towards  the  centre  of  the  nerve,  quite  different  from  the 
abrupt  edges  of  the  glaucomatous  cup.  The  disc  presents 
the  peculiar  bluish  or  milk}'  whiteness  of  atrophy,  its  ves- 
sels are  small,  and  there  is  little  or  no  displacement  of 
them  as  they  pass  from  the  margin  of  the  papilla  on  to 
the  retina.  For  a  description  of  the  glaucomatous  and 
the  physiological  excavations  of  the  optic  nerve,  see  arti- 
cle Glaucoma,  page  132. 

2.  Atrophy  of  the  Optic  Nerve  from  Disease  icithin  the 
Eye  ma}'  be  caiised  by  chronic  affections  of  the  choroid 
or  retina,  by  glaucoma,  by  acute  inflammation  of  the  eye, 
or  by  an  injury  producing  extensive  intraocular  hemor- 
rhage. As  the  original  disease  si  bsides,  the  cloudiness 
of  the  inflamed  structures  may  partially  and  sometimes 
completel}^  disappear,  but  the  retina  and  optic  nerve,  in- 
stead of  regaining  their  functions,  undergo  a  slow  process 
of  atrophy,  and  ultimatel}'  all  sight  is  extinguished.  The 
ophthalmoscopic  appearances  are  variable,  and  depend 
very  much  on  the  nature  of  the  affection  which  has  caused 
the  atrophy.  The  optic  papilla  is  ansiemic,  and  of  a  cloudy 
or  grayish-white,  but  it  has  not  generall}'  the  brilliant 
tendinous  whiteness  of  white  atrophy;  its  outline  is  often 
indistinct  or  irregular,  and  its  vessels  are  small  and 
shrunken.  In  some  cases  the  optic  disc  looks  absolutely 
smaller  than  normal,  and  this  is  especially  so  if  the  eye 


238  DISEASES    OF    THE    OPTIC    NERVE. 

Of 

is  soft  and  somewhat  shrunken.  A  cloudy  film  often 
pervades  the  whole  fundus,  and  blurs  the  appearance 
of  the  structures  behind  it.  Associated  with  this  con- 
dition of  the  eye,  there  are  frequently  to  be  seen  patches 
of  atro})hied  choroid  with  irregular  deposits  of  pigment, 
and  occasionally  also  a  partial  detachment  of  the  retina. 
The  Prognosis  and  Treatment. — The  prognosis  of  at- 
rophy of  the  optic  nerve  is  very  unfavorable.  The  only 
hope  is,  that  if  there  is  any  sight  remaining,  it  may  be 
still  retained.  Our  first  eftbrt  must  be  to  ascertain  the 
cause  of  the  atrophy,  and  then,  by  appropriate  remedies, 
to  arrest  the  progress  of  the  disease.  The  treatment  of 
the  various  att'ections  which  may  cause  atrophy  of  the  ret- 
ina and  optic  nerve  will  be  found  under  their  respective 
headings. 

Atrophy  of  the  Optic  Nerve  from  Tobacco. — The 
theory  that  tobacco,  in  excess,  will  produce  a  peculiar 
form  of  white  atroi)hy  of  the  optic  nerve,  has  received  the 
sanction  of  the  late  Dr.  Mackenzie,  and  of  Messrs. 
Critchett,  Wordsworth,  Hutchinson,  and  others.  My 
own  experience  at  the  Ophthalmic  Hospital,  however, 
leads  me  to  dissent  from  this  doctrine,  as  I  do  not  remem- 
ber ever  ha^ang  seen  a  case  in  which  the  loss  of  sight 
could  be  fairly  attributed  to  tobacco  only.  There  was 
always,  in  addition  to  the  immoderate  smoking,  some 
other  excess,  such  as  intemperance,  dissipation,  or  an 
undue  mental  strain  with  loss  of  rest. 

AMAUROSIS   AND    AMBLYOPIA. 

Amaurosis. — It  is  best  to  restrict  this  term  to  those 
cases  of  impaired  vision  and  blindness  which  are  due  to 
cerebral  or  cerebro-spinal  causes.  Before  the  discoverj^ 
of  the  ophthalmoscope,  amaurosis  was  the  generic  name 


AMAUROSIS.  289 

of  a  group  of  obscure  diseases  originating  either  witliin  or 
beyond  the  eye,  and  characterized  by  a  gradual  failure  of 
sight  usually  terminating  in  blindness.  With  increased 
facility  for  diagnosis,  most  of  these  affections  have  now 
been  traced  to  their  right  source,  and  have  received  their 
own  proper  name  and  place  in  the  list  of  ophthalmic  dis- 
eases. There  still,  however,  remain  a  large  number  of 
cases,  marked  by  a  progressive  diminution  of  sight,  de- 
pendent on  changes  in  the  brain  or  spinal  cord,  the  exact 
nature  of  which  we  are  unable  to  estimate  during  life,  and 
which  from  a  want  of  a  more  precise  knowledge  may  be 
conveniently  classed  under  the  heading  of  amaurosis. 

Although  the  cause  of  the  blindness  is  at  a  distance 
from  the  eye,  yet  secondarj^  changes  soon  take  place  in 
the  optic  papilla  which  enable  the  disease  to  be  recognized 
by  the  oj^hthalmoscope,  and  its  probable  progress  foretold. 

For  many  useful  suggestions  in  the  diagnosis  and  prog- 
nosis of  amaurotic  affections,  I  am  indebted  to  the  valu- 
able paper  on  "Amblyopia  and  Amaurosis,"  by  Yon 
Graefe.* 

In  the  examination  of  patients  suspected  to  be  suffer- 
ing from  amaurosis,  we  should  ascertain, 

1.  The  histor}'  of  the  case. 

2.  The  state  of  the  field,  and  the  acuteness  of  vision. 

3.  The  condition  of  the  optic  papilla, 

1.  The  history  of  the  case  always  affords  important  in- 
formation both  as  to  the  diagnosis  and  prognosis  of  the 
disease.  By  it  we  determine  whether  the  loss  of  sight 
was  sudden  or  gradual;  whether  it  was  preceded  by  head 
symptoms,  or  by  functional  disturbances  of  other  organs, 
as  the  kidneys,  the  liver,  or  the  uterus ;  or  whether  there 

*  TransUited  by  Mr.  J.  Zachariah  Laurence,  from  Zehender's 
Klin.  Monatsbl.  fiir  Aiigenheilkunde,  1865,  p.  129.  Ophtlialmic 
Keview,  No.  7,  p.  232. 


240  DISEASES    OF   THE    OPTIC    NERVE. 

had  been  any  previous  constitutional  disease,  such  as  gout, 
rheumatism,  or  syphilis. 

The  duration  of  the  impairment  of  sight  is  also  an  im- 
portant element  in  forming  a  prognosis ;  thus,  if  the  de- 
fective vision  has  been  for  some  months  stationary,  and 
all  evidences  of  the  disease  to  which  it  was  apparently 
due  have  passed  away,  a  favoralile  opinion  would  be  given ; 
whereas,  if  the  loss  of  sight  is  recent,  and  there  are  per- 
sistent head  symptoms,  we  should  conclude  that  the 
amaurosis  is  progressive,  and  will  probably  terminate  in 
blindness. 

2.  The  State  of  the  Field  and  the  Acuteness  of  Vision. — 
The  condition  of  the  visual  field  should  be  carefully  tested 
by  one  of  the  methods  described  at  page  252,  so  that  any 
imperfection  either  as  regards  its  periphery  or  its  con- 
tinuity of  surface  raa,y  be  accurately  noted,  as,  according 
to  Von  Graefe,  the  state  of  the  field  forms  a  good  basis 
on  which  to  ground  a  prognosis.  In  all  cases  of  amau- 
rosis, the  acuteness  of  central  sight  should  be  ascertained 
and  compared  witli  the  defects  and  extent  of  the  field  of 
vision.     The  following  variations  may  be  noticed. 

a.  With  diminished  acuity  of  central  vision,  the  field 
may  be  entire  in  its  periphery  and  continuous  throughout 
its  area,  whilst  the  visual  power  is  reduced  in  all  direc- 
tions. Such  cases  are  usually  stationarj^,  and  so  far  a 
hopeful  prognosis  may  be  given. 

/5.  With  diminished  acuity  of  central  vision,  the  field 
may  be  contracted  in  one  or  more  directions,  or  broken 
b}^  blind  patches  (scotomata),  whilst  the  visual  power 
throughout  the  rest  of  its  extent  is  greatly  lowered.  With 
these  sj'mptoms  the  disease  maj'  be  considered  progres- 
sive, and  the  prognosis  is  blindness. 

y.  There  ma}'  be  complete  loss  of  central  vision,  but 
with  ^  varying  coniiition  of  the  rest  of  the  field.  If  in 
such  cases  the  periphery  and  continuit^^  of  the  field  are 


AMAUROSIS.  241 

good,  there  is  reason  to  hope  that  the  disease  ma}^  be 
statioiiaiy,  although  there  is  but  a  slight  prospect  of  re- 
covering the  central  vision  which  has  been  lost.  The 
prognosis  is  therefore  favorable,  as  the  probability  is  that 
the  patient  will  not  go  blind.  If,  however,  in  addition  to 
the  central  scotoma,  there  are  other  blind  patches  in  the 
field,  or  the  periphery  is  much  contracted,  so  that  the 
eccentric  vision  is  greatly  reduced,  then  the  prognosis  is 
most  unfavorable,  and  blindness  may  be  predicated.  It 
must,  however,  be  remembered  that  the  prognosis  of  this 
form  of  central  amaurosis  does  not  appl^'  to  a  similar  state 
of  blindness  which  may  be  produced  by  retinal  hemor- 
rhage, or  some  other  disease  within  the  eye,  the  seat  of 
which  can  be  accurately  determined  by  the  ophthalmo- 
scope. 

8.  There  may  be  hemiopia  or  complete  loss  of  half  the 
field  of  vision,  in  many  cases  distinctly  marked  as  if  by  a 
vertical  line,  on  one  side  of  which  all  is  clear,  whilst  on 
the  other  all  is  dark.  There  are  tico  forms  of  hemiopia 
to  be  noticed,  the  fwst  called  equilateral^  from  the  corre- 
sponding halves  of  the  two  retinae  being  aflTected:  thus  the 
outer  half  in  one  ej'e,  and  the  inner  half  in  the  other,  may 
be  jointly  paralyzed,  or  the  reverse.  In  the  second  form, 
which  is  extremely  rare,  the  inner  halves  of  the  retinae 
of  the  two  eyes  are  blind,  but  the  hemiopia  is  more  diffuse, 
and  the  limitation  is  seldom  abruptly'  marked  as  in  the 
former.  To  understand  the  distinction  between  these  two 
classes  of  hemiopia,  it  is  necessary  to  refer  briefly  to  the 
anatomy  of  the  optic  tract,  commissure,  and  nerve.  The 
central  fibres  of  each  optic  tract  decussate  in  the  commis- 
sure, and  are  connected  with  the  optic  nerve  of  the  oppo- 
site side,  and  supplj-  the  inner  halves  of  the  retinae; 
whilst  the  outer  fibres  of  each  tract  go  to  the  optic  nerve 
of  the  same  side,  and  supply  the  outer  halves  of  the  retinte. 
Each  e3^e  thus  receives  nerve-fibres  from  both  optic  tracts, 

21 


242  DISEASES    OF    THE    OPTIC    NERVE. 

the  o?//t'r  luilf  of  the  retina  being  i:)rovi(lcd  with  lihunents 
from  its  own  tract,  whilst  the  inner  half  is  furnished  from 
the  one  of  the  opposite  side.  Hence  it  is,  that  a  clot  of 
blood,  or  a  tumor  pressing  on  the  optic  tract  only  of  one 
side,  say  the  right,  will  produce  hemiopia  of  the  outer 
half  of  the  right  eye,  and  the  inner  half  of  the  left.  If, 
howcA'er,  the  commissure  is  the  part  affected,  there  will 
be  hemiopia  of  the  inner  halves  of  both  e3'es.  In  testing 
the  field  of  vision,  the  student  must  not  forget  that  the 
right  half  of  the  field  corresponds  to  the  left  half  of  the 
retina,  and  vice  ve7'm. 

The  prognosis  of  hemiopia  must  depend  very  much  on 
the  cause  which  has  produced  it.  If  the  half  blindness 
originated  from  the  pressure  of  some  syphilitic  effusion 
on  the  optic  tract,  the  sight  may  be  regained ;  or  if  it  be 
from  the  presence  of  a  blood-clot,  there  is  reason  to  hope 
that  even  if  the  vision  should  not  be  restored,  the  defect 
may  remain  stationary ;  but  if  a  cerebral  tumor  be  sus- 
pected, the  prognosis  is  most  unfavorable. 

3.  The  condition  of  the  ojDtic  pa2:iilla  in  cases  of  ad- 
vanced amaurosis  is  that  of  white  atrophy,  as  described 
at  page  236. 

The  symptoms  which  are  associated  with  amaurosis  are 
very  variable.  In  one  class  of  cases  there  is  no  pain  in 
the  eye  or  head,  and  no  constitutional  disturbance,  the 
only  symptom  being  a  gradual  fading  awa}'  of  sight. 

In  another  class,  the  blindness  is  preceded  by  acute 
head  symptoms,  which  may  last  for  several  days  or  longer, 
and  then  either  cease  altogether,  or  greatly  diminish. 
With  the  cessation  or  diminution  of  the  pain  in  the  head, 
the  first  indications  of  failing  sight  are  noticed.  The 
patient  may  regain  his  health  and  the  full  enjoyment  of 
all  his  mental  and  physical  powers,  but  his  sight  steadily 
fades  until  he  is  in  absolute  darkness.  The  loss  of  vision 
in  these  cases  is  no  doubt  due  to  some  or<>anic  chanaes  in 


AMAUROSIS.  243 

the  brain,  produced  during  the  acute  inflammatory  attack, 
when  the  pain  in  the  head  was  severe.  The  cause  was 
transitory,  but  its  effects  are  permanent. 

In  a  third  class,  the  pain  in  the  head  is  continuous,  the 
patient  is  never  free  from  suffering.  Intense  headache 
is  the  first  symptom  of  the  disease,  and  it  precedes  the 
loss  of  sight.  Although  at  times  its  severitj'-  is  lessened, 
it  is  never  absent.  I  have  had  such  patients  tell  me  that 
they  would  not  mind  being  blind,  if  they  could  onlj^  be 
free  from  pain.  These  are  the  most  distressing  of  the 
amaurotic  cases;  we  can  do  nothing  for  the  absolute  blind- 
ness, and  but  little  for  the  constant  pain,  as  the  prepara- 
tions of  ojjium  are  seldom  tolerated. 

Amaurosis  maybe  associated  with  epileps}^, hemiplegia, 
and  locomotor  ataxy.  It  nia}^  also  occur  with  paraplegia: 
Dr.  Hughlings  Jackson  says,  "  Dr.  Brown-Sequard  has 
frequently  drawn  my  attention  to  cases  of  paraplegia  in 
which  amaurosis  has  also  existed,  without  any  other 
symptoms  to  suggest  disease  within  the  cranium."  .  .  . 
"  The  blindness  he  believes  is  the  result  of  eccentric  ii'ri- 
tation.    Dr.  Wilks  also  has  observed  several  such  cases."* 

State  of  the  Pupil. — In  the  early  sj-mptoms  of  amau- 
rosis dependent  on  brain  disease,  the  pupil  is  rather  di- 
lated and  sluggish;  but  in  the  later  stages  it  is  widely 
expanded  and  fixed,  giving  to  the  eyes  the  peculiar  vacant 
stare  which  is  so  characteristic  of  blindness  from  cerebral 
disease.  When,  however,  the  amaurosis  is  due  to  some 
afl[ection  of  the  spinal  cord,  the  pupil  is  frequently  con- 
tracted.    See  Myosis,  page  108. 

The  Causes  of  Amaurosis  may  be  chiefly  classed  under 
the  following  headings : 

1.  From  Disease  of  the  Cerebrum — Amaurosis  usually 

*  On  Defects  of  Sight  in  Brain  Disease.  Royal  London  Opli- 
thalmic  Hospital  Reports,  vol.  iv,  p.  17. 


244  DISEASES    OF   THE    OPTIC    NERVE. 

affects  both  ej-es ;  they  ma}^  be  attacked  simultaneously, 
or  the  blindness  may  be  more  advanced  in  one  than  the 
other,  but  as  a  rule  both  are  ultimately  involved.  This 
can  be  reasonably  anticipated  b}^  remembering  how  in- 
timately the  two  optic  nerves  are  associated  within  the 
brain  by  commissural  fibres.  Dr.  Hughlings  Jackson 
remarks :  "  The  kind  of  amaurosis  which  we  most  fre- 
quently find  with  disease  of  the  central  nervous  system 
is,  in  my  experience,  invariably  double,  although  one  eye 
may  suffer  before  the  other.  I  do  not  say  that  blindness 
of  one  eye  does  not  occur  loith  other  syiivptoms  of  disease 
of  the  nervous  system,  but  that  it  does  not  occur  from 
disease  of  the  brain-mass."*  Tumors  of  the  brain,  cere- 
bral hemorrhage,  softening  of  the  brain,  hydrocephalus, 
meningitis,  sj'philitic  deposits,  and  embolism,  may  all  be 
productive  of  amaurosis. 

2.  From  Disease  of  the  CerebeUum. — In  some  remarks 
which  Dr.  Hughlings  Jackson  kindly  gave  me  on  amau- 
rosis from  this  cause,  he  says  it  has  been  lon^  known 
that  blindness  may  coexist  with  disease  of  the  cei'ebel- 
lum,  but  it  is  by  no  means  clear  that  the  blindness  de- 
pends on  the  want  of  that  part  of  the  cerebellum  which 
the  disease  destroys.  For,  as  the  loss  of  sight  occurs 
only  when  the  disease  is  "coarse,"  such  as  from  tumors, 
blood-clot,  &c.,  he  believes  that  it  is  induced  b}^  the  irri- 
tation of  the  foreign  body  13'ing  in  the  brain,  and  not 
from  the  destruction  of  any  centre  connected  with  sight. 
As  a  consequence  of  this  irritation,  the  optic  nerves  be- 
come inflamed,  and  the  ultimate  loss  of  sight  is  due  to 
this  cause. 

3.  From  Disease  of  the  Sjnnal  Cord. — Amaurosis  may 
occur  with  paraplegia,  and  it  is  frequently  met  with  in  lo- 

*  On  Defects  of  Sight  in  Diseases  of  the  Nervous  Sj'stem. 
Koyal  London  Ophthalmic  Hospital  Reports,  vol.  iv,  p.  390. 


AMAUROSIS.  245 

coinotor  ataxy,  and  especially  Avhen  the  disease  is  in  an 
advanced  stage.  The  blindness  is  usually  confined  to 
one  eye.  Dr.  Trousseau*  says  "  both  ej'es  may  be  affected, 
although  this  rarely  happens."  The  pupil  in  spinal  amau- 
rosis is  frequently  contracted,  and  this  is  generally  the 
case  when  the  part  of  the  cord  affected  is  in  the  cervical 
region. 

4.  From  Uterine  Derangements. — A  verj^  acute  form  of 
amaurosis,  which  will  run  its  course  to  blindness  in  a  few 
days  or  weeks,  is  occasionally  produced  by  a  sudden  sup- 
pression of  the  menses.  It  is  usually  accompanied  by 
intense  headache,  with  vomiting  or  a  feeling  of  nausea. 
In  one  case  which  I  published, f  so  rapid  was  the  loss  of 
sight,  that,  in  fifteen  days  from  the  first  symptoms,  tlie 
patient  retained  but  little  more  than  a  mere  perception 
of  light  with  either  eye.  Examined  with  the  ophthalmo- 
scope, the  retinal  circulation  was  seen  to  be  interrupted ; 
the  return  flow  of  blood  was  impeded.  Although  the 
symptoms  were  those  of  pressure  on  some  part  of  the 
cerebrum,  yet,  whether  the  pressure  was  caused  by  dis- 
tension of  the  vessels,  or  by  an  effusion  of  blood,  lymph, 
or  serum,  could  only  be  conjectured.  Under  the  influ- 
ence of  10  gr.  doses  of  the  iodide  of  potassium,  the  func- 
tions of  tlie  uterus  were  restored  at  the  next  monthlj'  pe- 
riod, and  the  patient  began  gradually  to  recover  her 
sight.  In  three  months  she  was  able,  with  one  eye,  to 
read  No.  1,  and,  Avith  the  other,  No.  10  of  Jaeger's  test 
types.  The  report  concludes  by  stating  that  the  im- 
provement was  still  progressing.  Amenorrhoea,  or  ir- 
regular and  scanty  menstruation,  may  also  cause  amauro- 
sis ;  but  the  symptoms  are  more  chronic  than  when  in- 

*  Trousseau's  Clinicjil  Medicine,  translated  by  the  Sydenham 
Society,  vol.  i,  p.  156. 

f  Medical  Times  and  Gazette,  August  1,  18G3. 
21* 


246  DISEASES    OF    THE    OPTIC    NERVE. 

duced   by  an  acute  suppression.      (See  Treatment  of 
Neuro-Retinitis,  page  234.) 

In  some  obscure  manner  amaurosis  is  occasionally  con- 
nected with  pregnancy.  A  remarkable  instance  of  this 
form  of  blindness  came  under  my  care  at  the  Ophthalmic 
Hospital,  and  will  be  found  related  in  our  Reports.*  The 
amaurosis  was  recurrent;  it  commenced  during  the  gesta- 
tion of  the  eighth  child,  and  recurred  in  each  succeeding 
pregnancy.  After  the  birth  of  her  eighth  child,  the  pa- 
tient regained  sufficient  sight  to  read  No.  10  of  Jaeger, 
and  to  do  needlework;  but,  after  the  ninth,  her  recover}' 
was  less  complete,  and,  in  the  sixth  month  of  her  tenth 
pregnancy,  she  had  become  blind  with  one  e3'e,  and  could 
only  count  fingers  with  the  other. 

5.  From  loss  of  Blood. — Amaurosis  may  occur  from  a 
large  and  rapid  loss  of  blood.  I  have  known  it  come 
on  suddenly  from  extensive  flooding  during  parturition, 
and  the  blindness  has  been  permanent.  Cases  haA^e  also 
been  reported,  in  which  it  has  followed  vomiting  of 
blood.  The  loss  of  sight  may  be  immediate,  or  it  may 
be  gradual. 

6.  From  Reflex  Irritation. — Amaurosis  maj'  be  induced 
from  injur}'  or  disease  involving  branches  of  the  fifth 
nerve,  at  a  distance  from  the  eye.  Several  instances  have 
been  quoted  by  Mr.  Hutchinson, f  which  illustrate,  as  he 
saj's,  "more  or  less  directly  the  influence  of  the  sensitive 
nerves  of  the  face  upon  the  functions  or  nutrition  of  the 
eyeball."  In  some  cases  the  blindness  is  i:)receded  by 
intense  neuralgia,  whilst  in  others  there  has  been  a  loss 
of  sensibility  on  one  side  of  the  face.  A  very  interesting 
case  of  amaurosis  of  one  eye,  consequent  on  acute  abscess 
of  the  antrum,  produced  b}'  a  carious  tooth,  has  been  re- 

*  lioyal  London  Ophtliahnic  Hospital  Reports,  vol.  iv,  p.  65. 
t  Ibid.  p.  120. 


AMBLYOPIA.  247 

corded  by  Mr.  James  Salter.*  The  loss  of  sight  was 
permanent. 

3Ionocular  amaurosis  may  arise  from  any  cause  which 
induces  pressure  on  the  optic  nerve  of  one  eye  onl}^,  such 
as  a  tumor  or  some  syphilitic  exudation,  either  just  within, 
or  immediately  external  to  the  orbit ;  or  it  may  be  pro- 
duced by  embolism,  or  bj^  disease  of  the  spinal  cord. 

For  the  treatment  of  amaurosis,  no  definite  course  can 
be  laid  down;  the  blindness  is  secondary  to  so  many  dis- 
eases. The  cause  of  the  defective  sight  must  be  sought 
for  by  a  careful  examination  into  the  history  and  the  ac- 
companj'ing  symptoms.  The  most  hopeful  cases  are  those 
which  are  acute  and  dependent  on  some  sudden  arrest  of 
the  function  of  one  of  the  internal  organs,  or  upon  pre- 
vious sj'philitic  disease,  and  where  sufficient  time  has  not 
elapsed  for  any  organic  changes  to  have  taken  place 
either  from  the  pressure  of  inflammatory  exudations,  or 
from  atrophy. 

Amblyopia  {amSkuq,  dull,  a></>,  the  eye)  has  the  same 
signification  as  amaurosis  (a/jLuupow,  to  render  obscure), 
the  former  meaning  dull  vision,  the  latter  obscure.  These 
synonymous  terms  have  created  great  confusion,  as  the}"" 
have  not  only  been  applied  indifterentl}',  but  lately  they 
have  been  used  in  combination  ;  thus,  a  form  of  blindness 
has  been  described  under  the  title  "  Amaurotic  Ambly- 
opia." It  would  be  well  to  restrict  the  name  Amblyopia 
to  those  impairments  of  sight  which  are  apparently  due 
to  imperfect  perception  from  defective  innervation,  or  to 
a  loss  of  the  nervous  sensibility  of  one  e^^e  from  disuse. 
In  this  sense  the  word  has  been  applied  by  man}-  to  de- 
note the  dull  sight  which  is  so  frequently  found  in  one 
eye  in  cases  of  strabismus,  wheie  no  structural  change 

*  Modico-Cbirurgiciil  Transactions,  vol.  xlv. 


248  DISEASES    OF    THE    OPTIC   NERVE. 

can  be  detected  by  the  ophthalmoscope  to  account  for 
the  loss  of  power.  The  term  amblyopia  may  be  also 
rightly  used  to  designate  the  dimmed  vision  brought  on 
either  by  the  retina  being  over-wrought,  or  by  its  being 
rendered  dull  and  unimpressible  from  drink  and  de- 
bauchery. 

Hemeralopia — Day-sighf,  N'ighf-hlind)7ess — is  a  defect 
of  sight  varying  in  degree  from  dimness  to  almost  com- 
plete darkness  after  the  sun  has  gone  down.  It  is  most 
frequentl}'  met  with  amongst  sailors,  soldiers,  and  others 
who  have  been  much  in  the  tropics.  It  is  due  to  a  blunted 
sensibilit}^  of  the  retina,  Avhich  fails  to  appreciate  fully 
the  impressions  which  are  produced  b}'  a  dim  light. 
Night-blindness  is  frequently  met  with  in  retinal  aflec- 
tious,  and  especiall}'  in  retinitis  pigmentosa;  but  the 
hemeralopia,  to  which  I  now  refer,  is  a  functional  dis- 
ease, and  quite  independent  of  any  structural  change. 

Causes. — Although  the  constant  exposure  to  strong 
glare  exercises  a  certain  influence  in  producing  night- 
blindness,  yet  the  predisposition  to  it  is  given  by  an  im- 
paired and  debilitated  state  of  heath.  In  this  opinion, 
all  wlio  have  had  much  experience  of  this  affection  seem 
to  be  agreed.  During  the  Crimean  war,  hemeralopia 
was  frequent  both  amongst  the  soldiers  and  sailors,  and 
the  evidence  of  the  medical  officers  coincided  in  attrib- 
uting it  to  either  scurvy  or  debility  from  exposure  and 
privation.*  In  a  paper  b}'  Dr.  Alexander  Bryson,  "On 
Night-blindness  in  connection  with  Scurvy, "f  he  says 
"that  it  most  unquestionabl}-  occurs  much  more  fre- 
quently in  scurvy  than  is  generall}'  supposed,  but,  in 
consequence  of  the  simultaneous  existence  of  some  more 

*  Royal  Loiiilun  Ophthalmic  Hospital  Reports,  vol.  ii,  p.  35. 
t  Ibid.  1..  40. 


HEMERALOPIA.  249 

serious  sj-mptoms  of  a  less  ambiguous  character,  it  fre- 
quently passes  unnoticed."  He  then  adduces  some  forcible 
examples  of  hemeralopia  occurring  with  scurvy  amongst 
ships'  crews,  all  of  which  were  successfully  treated  by 
giving  the  eyes  rest,  and  curing  the  scorbutic  s3'niptoms 
by  a  proper  diet  of  fresh  meat  and  vegetables  ;  and  he 
concludes  by  expressing  his  opinion  that  the  disease  is 
"  entirely  dependent  on  an  improper  or  erroneous  diet." 

Hemeralopia  has  also  been  attributed  to  ague,  or  to 
some  other  form  of  marsh  fever.  My  own  experience, 
however,  of  the  disease  is,  that  it  is  peculiarly  liable  to 
attack  patients  whose  eyes  have  been  long  subjected  to 
excessive  glare,  and  whose  constitutions  have  been  de- 
bilitated either  from  scurvy,  ague,  or  from  a  diet  deficient 
both  in  quantity  and  in  qualit3% 

Examined  loitk  the  Ophthalmoscope^  no  change  can  be 
detected  in  the  choroid,  retina,  or  optic  nerve,  to  account 
for  the  impairment  of  function. 

Treatment — If  there  is  any  evidence  of  scurvy,  an 
anti-scorbutic  diet  should  be  prescribed,  with  two  or  three 
oranges,  or  the  juice  of  one  or  two  lemons  dailj'.  The 
citrate  of  potash  may  be  also  given  twice  or  three  times 
a  day,  and  if  there  is  ana?niia,  each  dose  may  be  com- 
bined with  gr.  3  to  gr.  5  of  the  citrate  of  ammonia  and 
iron. 

If  ague  or  remittent  fever  can  be  traced  as  a  possible 
cause  of  the  disease,  quinine  should  be  freely  given,  and 
continued  for  at  least  six  or  eight  weeks.  The  ej'es  should 
be  rested,  and  all  exposure  to  glare  or  strong  lights 
avoided.  I  have  tried  keeping  the  patient  in  absolute 
darkness  for  a  week  at  a  time;  but  the  relief  was  not  suf- 
ficient to  compensate  for  so  long  an  exclusion  from  light. 
Blisters  to  the  temples  and  behind  the  ears,  are  perfectly 
useless,  they  only  serve  to  irritate  the  patient,  and  do  no 
good. 


250  DISEASES    OF   THE   OPTIC    NERVE. 

Snow-blindness  is  a  temporary  loss  of  sight  from  the 
dazzling  caused  by  brilliant  whiteness.  A  similar  con- 
dition is  produced  by  the  excessive  glare  of  artificial 
light.  I  have  had  patients  from  the  light-ships  around 
the  coast,  who  have  complained  that,  after  trimming  the 
lamps  at  night,  they  have  been  for  some  minutes  abso- 
lutely blinded,  and  that  they  have  not  completely  re- 
covered from  the  paratyzing  effects  of  the  intense  glare 
for  some  hours. 

The  treatment  consists  in  wearing  dark  neutral-tint 
glasses,  to  diminish  the  intensity  of  the  light. 

Color -Blindness —  Ghrovio-pseudopsis  — Dichromic 
Vision — is  a  defect  of  sight,  by  which  the  power  of  dis- 
tinguishing colors  is  either  diminished  or  lost.  The  ex- 
periments of  Professor  Maxwell  on  the  mixture  of  the 
colors  of  the  spectrum,*  show,  "that  for  the  normal  eye 
there  are  three,  and  only  three,  elements  of  color;  and 
that  in  the  color-blind  one  of  these  is  absent."  He  has 
further  proved,  that  "  the  elementary  sensation  which 
they  do  not  possess,  is  that  which  is  excited  in  the  normal 
ej^es  by  the  extreme  red  end  of  the  spectrum."  Hence, 
he  concludes,  that  "  color-blind  vision  is  not  onl3^  dichro- 
mic, but  the  two  elements  of  color  are  identical  Avith  two 
of  the  three  elements  of  color  as  seen  b}'  the  ordinar3"  e3'e ; 
so  that  it  differs  from  ordinary  vision  only  in  not  perceiv- 
ing a  particular  color,  the  relation  of  which,  to  known 
colors,  ma}^  be  numericall}"  defined."  According  to  the 
same  authority',  a  color-blind  person  sees  red  and  sea- 
green,  as  graj^;  scarlet  and  green,  as  yellow;  and  rose- 
color  and  blue-green,  as  blue;  whilst  he  distinguishes  the 
shades  of  red  from  each  other,  and  also  the  shades  of 
green  from  each  other.     If  such  a  person  looks  at  a  red 

*  Philoeophical  Transactions,  1860. 


COLOR-BLINDNESS.  251 

and  a,  groen  through  a  red  glass,  the  green  will  appear 
darker,  but  the  red  will  be  nearly  as  bright  as  before; 
and,  if  he  uses  a  green  glass,  the  red  will  be  darkened, 
but  the  green  will  be  little  altered.  "In  this  manner," 
Mr.  Maxwell  saj'S,  "  I  have  made  color-blind  people  dis- 
tinguish the  colors  of  a  Turkey  carpet."  If,  therefore, 
he  suggests,  one  who  is  color-blind  had  the  courage  to 
wear  a  pair  of  spectacles  with  one  eye  red  and  the  other 
green,  he  would  probably,  in  course  of  time,  come  to  form 
a  judgment  of  red  and  green  things  intuitively.  He  would 
never  acquire  our  red  sensation  ;  but  if  he  really  wished 
to  know  what  things  were  red  and  what  green,  he  would 
learn  to  do  so  as  well  as  if  one  had  been  marked  with  an 
R,  and  the  other  with  a  G.  Professor  Pole,  in  his  ac- 
count of  his  own  color-blindness,*  states  that  his  vision 
was  perfectly  dichromic.  He  could  distinguish  clearly 
blue  and  yellow,  and  the  colors  produced  by  their  com- 
bination, but  he  could  not  tell  red  from  green.  "  The 
appearance  of  the  green  division  in  Chevreul's  color 
circle,"  he  saj^s,  "  corresponds  with  that  of  the  red  or 
opposite  one." 

There  are  three  varieties  of  color-blindness  met  with  in 
practice : 

1.  The  dichromic  vision  just  described,  in  which  the 
sensation  of  red  is  wanting. 

2.  The  inability  to  distinguish  shades  of  color. 

3.  Achromatic  vision,  or  the  want  of  power  to  recog- 
nize any  color,  everything  appearing  as  either  white, 
black,  or  gray. 

1.  The  dichromic  form  of  color-blindness  is  usually"  a 
congenital  defect,  but  it  may  also  occasionally  be  the  re- 
sult of  disease. 

2.  The  inability  to  distinguish  shades  of  color  may  be 

*  Philosophical  Transactions,  1859. 


252  DISEASES    OF    THE    OPTIC    NERVE. 

congenital,  but  it  may  also  be  induced  from  over-use,  or 
the  constant  strain  of  the  e3'es  in  looking  at  colors.  I 
had  a  patient  under  my  care  at  the  hospital  who  had  been 
engaged  for  many  years  in  a  color  warehouse,  and  whose 
chief  business  consisted  in  sorting  and  matching  colors. 
For  this  duty  he  had  acquired  a  special  reputation 
amongst  his  fellows.  Gradually,  however,  his  powers 
began  to  fail  him,  and  when  he  applied  to  the  hospital  for 
relief,  he  could  only  distinguish  whole  colors,  and  had 
lost  the  faculty  of  discriminating  shades  of  tint. 

3.  Achromatic  vision  is  rare,  and  is,  I  believe,  gener- 
ally produced  by  disease.  Dr.  J.  J.  Chisholm,  of  Charles- 
ton, S.  C.  (II.  S.  A.),  has  related  a  case  of  optic  neuritis 
in  which  the  patient's  vision  was,  for  a  time,  achromatic. 
"  The  restoration  to  chromatic  vision  showed  itself,"  he 
says,  "  in  a  slowly-growing  perception  of  blue  shades. 
After  some  months,  the  shades  of  yellow  could  be  per- 
ceived. Reds  cannot  yet  be  detected.  All  shades  of  red 
appear  brown."* 

Dr.  Argyll  Robertson  has  also  published  a  case  of 
spinal  disease,  in  which  myosis  and  color-blindness  ex- 
isted. The  patient  lost  all  perception  of  colors,  although 
previous  to  his  illness  he  used  to  distinguish  them 
readily.f 

To  Ascertain  the  Perfection  of  the  Field  of 
"Vision,  the  patient  should  be  placed  about  one  and  a 
half  feet  in  front  of  the  surgeon,  and  having  closed  his 
sound  eye  with  his  hand,  he  should  be  told  to  look  steadily 
with  the  affected  one  at  the  nose  or  the  eye  of  the  exam- 
iner.    Whilst  the  eye  is  thus  fixed,  the  surgeon  should 

*  lloyal  London  Oplithahiiic  Hospital  lleports,  vol.  vi,  p.  214. 
f  Eye  Symptoms  in  Spinal  Disease.     Oliver  and   Bo3'd,  Edin- 
burgh, 1869. 


THE    OPHTHALMOSCOPE.  253 

keep  one  or  both  of  his  hands  moving  gentl}^  along  the 
line  of  the  circumference  of  an  imaginary  circle  which 
about  corresponds  with  the  normal  field  of  vision,  care- 
fully noting  those  points  at  which  the  patient  says  the 
hand  becomes  either  indistinct  or  lost.  If  the  patient 
should  be  unable  to  distinguish  the  movements  of  the 
hand  at  one  and  a  half  feet,  it  may  be  approximated  to 
the  eye,  and  a  smaller  circle  be  described ;  the  parts  at 
which  the  sight  is  the  most  defective  or  wanting  being 
still  accurately  observed. 

To  ma]^  out  the  field  of  vision ^  the  patient  should  be 
directed  to  stand  in  front  of  a  black  diagram-board, 
placed  at  twelve  inches  distance  from  him.  Covering 
with  his  hand  the  eye  w-hich  is  not  under  examination, 
he  should  fix  the  other  on  a  small  white  cross  which  has 
been  drawn  in  the  centre  of  the  board  and  on  a  level  with 
his  eyes.  Whilst  his  eye  is  thus  fixed  b}^  steadily  look- 
ing on  the  cross,  a  small  white  disc  at  the  end  of  a  piece 
of  wire  is  to  be  moved  in  different  directions  over  the 
board,  and  at  whatever  spot  it  is  clearly  seen,  a  -f  is  to 
be  made;  when  only  dimly  recognized,  a  — ;  and  when 
not  visible,  an  0.  Each  series  of  symbols  are  now  to  be 
connected  with  lines,  and  a  map  will  be  thus  drawn  which 
w'ill  fairly  represent  the  patient's  field  of  vision. 

To  facilitate  the  copying  and  reduction  of  such  a  dia- 
gram, the  board  should  be  ruled  in  three-inch  squares, 
when  the  drawing  can  be  easily  transferred  to  properly 
ruled  paper. 

THE    OPHTHALMOSCOPE. 

Ophthalmoscopes  are  divided  into  two  classes : 

1.  The  homocentric,  with  the  mirror  concave. 

2.  The  heferocentric,  with  the  mirror  plane  or  convex, 
to  the  side  of  which  is  attached  a  movable  arm  support- 
ing a  biconvex  lens. 

22 


254  THE   OPHTHALMOSCOPE. 

Tlie  mirrors  may  be  made  of  silvered  glass  or  of  pol- 
ished metal ;  the  latter  is  preferred,  as  the  illumination 
is  less  intense  than  from  the  former,  and  is  yet  suflicient 
for  all  ophthalmoscopic  purposes. 

There  are  jwi-table,  fixed,  and  hinoculai-  ophthalmo- 
scopes. 

The  Portable  Monocular  Ophthalmoscopes  are 
chiefly  used,  and  of  these  the  most  eflicient  are  Lieb- 
reich's,  Coccius's,  and  Zehender's. 

Liebreich's  Ophthalmoscope  (Fig.  25)  consists  of  a 
polished  concave  metal  mirror  one  and  a  quarter  inch  in 
diameter,  and  of  about  eight  inches  focal  length,  with  a 
sight-hole  about  one  line  in  diameter  in  the  centre.  This 
is  cased  in  a  rim  of  metal  with  a  bact-piece  perforated  to 
correspond  with  the  aperture  in  the  mirror.  At  the  lower 
and  central  part  of  the  rim  a  handle  is  fixed,  and  at  the 
side,  on  a  level  with  the  sight-hole,  there  is  attached  a 
jointed  arm  which  supports  a  clip  for  an  ocular  lens,  to  be 
placed,  when  required,  at  the  back  of  the  mirror.  This 
lens  ma}^  be  either  concave  or  convex,  according  to  the 
requirements  of  the  person  who  uses  the  ophthalmo- 
scope. 

Coccius's  Ophthalmoscope  (Fig.  20)  consists  of  a  ^:>/o?/p 
metal  mirror,  set  in  a  metal  frame,  which  is  furnished  with 
a  handle  and  clip  for  an  ocular  lens,  as  in  Liebreich's 
ophthalmoscope.  It  has,  however,  in  addition,  a  jointed 
arm  at  the  top  of  the  stem,  with  a  clip  for  a  large  bicon- 
vex lens  of  about  five  inches  focal  length,  which  is  placed, 
when  the  instrument  is  used,  at  a  certain  angle  with  the 
mirror,  on  which  it  collects  the  rays  of  light  from  the  lamp. 

The  following  is  Mr.  Soelberg  Wells's  account  of  the 
mode  of  using  Coccius's  ophthalmoscope  :  "  The  collect- 


zeiiender's  ophthalmoscope.  255 

ing  lens  is  to  be  tiivned  towards  the  flame,  which  should 
be  somewhat  more  than  twice  the  distance  of  the  focal 
length  of  the  lens  from  the  observer.  The  mirror  is  then 
to  be  set  somewhat  slanting  to  the  lens  and  the  eye  of  the 

Fig.  2.J.* 


patient.  If  the  mirror  is  properly  adjusted  for  the  lens 
and  the  flame,  we  shall  obtain,  if  we  throw  the  image  of 
the  flame  upon  the  palm  of  our  hand  or  the  cheek  of  the 
patient,  a  bright  circle  of  light,  with  a  small  dark  central 
spot,  which  corresponds  to  the  opening  in  the  speculum. 
The  dark  spot  is  then  to  be  thrown  into  the  pupil  of  the 
eye  under  examination,  the  surgeon  placing  the  mirror 
close  to  his  own  e3^e,  and  looking  through  the  aperture 
into  the  patient's  eye,  which  should  afford  a  bright  lu- 
minous reflex. "f  For  the  indirect  examination  a  bicon- 
vex lens  of  from  two  to  three  inches  focus  will  be  required 
to  be  held  in  front  of  the  eye,  as  with  other  ophthalmo- 
scopes. 

Zeiiender's   Ophthalmoscope   consists   of  a   convex 
metal  mirror,  set  in  a  metal  frame,  and  furnished  with 

*  Copied  from  HulUe  on  the  Ophthalmoscope, 
f  "VVells's  Treatise  on  Diseases  of  tiie  -Eye,  p.  292. 


256  THE    OPHTHALMOSCOPE. 

clips  for  an  ocular  niul  a  lateral  biconvex  lens,  in  the  same 
manner  as  Coccins's. 

Of  these  three  instrnments  I  prefer  Liebreich's :  the 
student  can  learn  how  to  use  it  with  more  rapidity  than 
either  of  the  other  ophthalmoscopes,  and  it  answers  well 
all  the  practical  purposes  for  which  it  is  required.  Coc- 
cius's  instrument  is  considered  by  many  to  be  superior  to 
Liebreich's,  and  its  claims  have  been  speciallj^  advocated 
by  those  who  have  long  worked  with  it.  The  advantages 
which  it  has  over  Liebreich's,  are,  that  hy  means  of  the 
collecting  lens  the  focal  length  of  the  mirror  can  be 
changed,  and  the  degree  of  illumination  increased  or  di- 
minished ;  there  is  less  reflection  from  the  cornea ;  and  it 
is  more  efficient  for  direct  examination.  The  merit  which 
is  claimed  for  Zehender's  ophthalmoscope,  is  that  it  is  the 
best  for  direct  examination  ;  but  for  the  inverted  image  it 
is  inferior  to  the  other  two. 

A  very  portable  and  convenient  ophthalmoscope  is 
made  by  Messrs.  Weiss.  It  consists  of  a  very  slightly 
concave  silvered  glass  mirror,  inclosed  in  a  pocket-case 
with  a  two,  or  two  and  a  half  inch  focus  lens.  The  mirror 
is  framed  and  backed  with  horn  ;  and  the  lens  is  encircled 
with  a  frame  of  suflicient  dei)th  to  protect  its  central 
prominent  part  from  being  scratched  when  it  is  laid  on 
the  table. 

Fixed  Ophthalmoscopes  are  too  large  and  heavy  to  be 
of  much  sei'vice  except  for  demonstration,  or  for  artistic 
purposes.  When  once  adjusted  to  the  patient's  eye,  a 
number  of  students  can  look  through  the  instrument  in 
succession  ;  or  a  sketch  of  the  fundus  can  be  readily  taken, 
as  the  eye  is  kept  under  observation  whilst  both  hands  of 
the  surueon  are  free  for  drawing.     The  best  of  the  fixed 


BINOCULAR    OPHTHALMOSCOPES.  257 

Ophthalmoscopes  is  Liebreich's,  or  a  modification  of  it  by 
Messrs.  Smith  and  Beck. 

Binocular  Ophthalmoscopes. — The  adA'antages  of 
using  both  eyes  in  making  ophthalmoscopic  examinations 
are  A'ery  great.  With  a  binocular  instrument  a  stereo- 
scopic view  is  gained  of  the  fundus  of  the  eye.  Some  parts 
are  seen  in  relief,  whilst  others  stand  out  in  a  manner 
which  it  is  impossible  even  for  the  most  practised  observer 
to  obtain  with  a  monocular  ophthalmoscope.  In  using  a 
binocular  instrument,  the  lamp  should  be  placed  behind 
and  above  the  head  of  the  patient.  It  is  of  course  es- 
sential that  the  observer  should  himself  possess  binocular 
vision,  and  that  the  ophthalmoscope  should  be  so  adjusted 
as  to  enable  him  to  look  through  both  sight-holes  and  see 
a  single  object.  The  two  best  binocular  instruments  are, 
one  by  Dr.  Giraud-Teulon,  the  inventor  of  the  first  bin- 
ocular ophthalmoscope,  made  by  M.  Xachetof  Paris  ;  and 
the  other  b}'  Messrs.  Laurence  and  Heisch,  made  by 
Messrs.  Murray  and  Heath  of  London. 

How  TO  WORK  WITH  THE  OPHTHALMOSCOPE, — To  Com- 
pletely explore  the  whole  fundus  of  the  eye  and  to  ascer- 
tain the  state  of  the  lens  and  the  vitreous,  the  pupil  should 
be  widely  dilated  with  atropine  ;  but  where  the  desired  in- 
formation can  be  obtained  witliout  such  a  thorough  in- 
vestigation, it  will  be  unnecessary  and  undesirable  to  sub- 
mit the  patient  to  this  annoyance.  The  examination  must 
be  conducted  in  a  darkened  room,  and  with  a  lamp  pro- 
vided with  a  bright  steady  flame.  The  most  convenient 
light  is  a  small  gas  lamp  at  the  end  of  a  movable  arm, 
which  can  be  turned  in  all  directions  and  raised  or  lowered 
as  may  be  required.  The  burner  should  be  a  porcelain 
argand,  protected  with  a  piece  of  wire  gauze  below  to 
regulate  the  draught.     The  chimney  should  be  a  tube  of 

22^ 


258  THE    OPHTHALMOSCOPE. 

plain  white  glass,  of  a  uniform  diameter  throughout  its 
length.  When  gas  cannot  be  obtained,  a  moderator  or  a 
reading  lamp  without  the  shade  will  answer  almost  as 
well.  With  all  ophthalmoscopes,  except  the  binocular,  it 
will  be  found  most  convenient  to  place  the  lamp  on  the 
left-hand  side  of  the  patient,  and  with  the  flame  on  a  level 
with,  and  a  little  behind  the  e3'es  to  be  examined. 

To  use  a  monocular  hand  ophthalmoscope — say  Lieb- 
reich's — the  observer  sits  or  stands  in  front  of  the  pa- 
tient, so  that  his  ej^es  are  a  little  above  the  level  of  those 
under  examination,  and  at  about  eighteen  or  twentj^ 
inches  distance  from  them.  He  then  with  one  baud  holds 
the  ophthalmoscopic  mirror  close  to  his  owai  e^^e,  and  at 
such  an  angle  that  he  catches  upon  its  polished  surface 
the  rays  of  light  from  the  lamp,  and  reflects  them  into  the 
eye  of  the  patient.  Looking  through  the  sight-hole  of 
the  mirror  into  the  eye  thus  illumined,  he  jiroceeds  to 
make  either  an  indirect  or  a  direct  examination  of  its 
fundus. 

For  the  indirect  method  he  holds  in  his  other  hand,  be- 
tween his  forefinger  and  thumb,  an  object-glass  of  two  or 
two  and  a  half  inch  focus  in  front  of  the  patient's  eye,  and 
at  from  one  and  a  half  to  two  inches  distance  from  it, 
steadying  the  lens  b}' resting  his  fingers  on  the  forehead, 
as  represented  in  the  woodcut  (Fig.  27).  B^-  moving  his 
own  head  a  little  backwards  or  forwards  as  ma3'  be  re- 
quired, he  soon  succeeds  in  bringing  into  view  a  clearl3' 
marked  inverted  aerial  image  of  the  fundus  of  the  eye  he 
is  examining. 

The  size  of  the  inverted  image  ma^'  be  increased  bj^ 
placing  an  ocular  convex  lens  of  about  ten  inch  focus  in 
the  clip  behind  the  sight-hole  of  the  mirror,  and  using  at 
the  same  time  an  object-glass  of  from  three  to  four  inch 
focus.  With  this  combination  it  will  be  necessary  to  ap- 
proach the  head  nearer  to  the  patient's  eye.     In  order  to 


INDIRECT    METHOD.  259 

obtain  a  view  of  the  various  parts  of  the  fundus  in  suc- 
cession, it  is  requisite  to  direct  the  patient  to  turn  his  eye 
in  different  directions,  and  for  this  purpose  it  is  conve- 
nient to  have  fixed  objects  to  Avhich  to  call  his  attention. 

Fig.  27. 


To  see  the  optic  nerve,  the  patient  should  be  told  to  look 
at  the  tip  of  the  observer's  ear  most  distant  from  him ; 
thus  if  the  right  e^'e  is  under  examination,  he  should  look 
at  the  right  ear  of  the  surgeon.  By  this  means  the  globe 
is  slightly  inverted,  and  the  optic  papilla  is  brought  uuder 
observation. 

To  examine  the  ^^ellow  spot,  the  patient  should  be  di- 
rected to  look  straight  before  him  at  the  eye  of  the  sur- 
geon, or  through  the  sight-hole  of  the  mirror. 

For  the  direct  method,  or  the  examination  of  the  erect 
image,  no  object-glass  will  be  required.  The  best  oph- 
thalmoscope for  this  purpose  is  Zehender's  or  Coccius', 
either  of  which  is  to  be  preferred  to  Liebreich's.  The 
surgeon  will  have  to  approximate  the  mirror  to  within 
one  and  a  half  or  two  inches  of  the  eye  under  examina- 
tion.    If  either  the  surgeon  or  patient  is  myopic,  a  con- 


260  ANOMALIES    OF    REFRACTION. 

cave  ocular  lens  should  be  placed  behind  the  sight-hole 
of  the  mirror.  When  it  is  desirable  to  fully  explore  the 
fundus,  the  pupil  should  be  dilated  with  atropine. 

Lateral  or  Focal  Illumination  of  the  eye  is  an  ex- 
tremely useful  means  for  examining  the  surface  of  the 
cornea  or  the  iris,  and  for  ascertaining  the  state  of  the 
lens  in  cases  of  suspected  cataract.  The  pupil  having 
been  first  widely  dilated  with  atropine,  the  patient  is 
seated  on  a  chair,  and  the  lamp  is  so  placed  that  its  flame 
is  on  a  level  with,  and  a  little  in  front  of  his  eye,  and  at 
about  two  feet  distance  from  it.  A  biconvex  lens  of  two 
or  two  and  a  half  inch  focus,  is  then  held  so  as  to  con- 
centrate a  cone  of  light  upon  the  e^'e,  when,  by  a  slight 
movement  of  the  glass  in  ditferent  directions,  each  part 
of  the  structure  under  examination  is  in  turn  illumined, 
until  the  whole  of  it  has  been  satisfactorily  explored.  A 
second  lens  ma}'  be  held  in  front  of  the  eye,  to  be  used 
as  a  magnifier,  if  required. 

For  a  detailed  account  of  the  theory,  and  use  of  the 
ophthalmoscope,  I  must  refer  the  reader  to  the  excellent 
treatises  b}'  Messrs.  Hulke  and  Henr}'  Wilson,  and  to  Mr. 
Carter's  translation  of  Zander's  work,  with  notes  and  ad- 
ditions by  the  translator. 


CHAPTER  YI. 

ANOMALIES    OF    REFRACTION    AND    DISEASES    OF    ACCOMMO- 
DATION. 

Anomalies  of  Refraction  and  Diseases  op  Accom- 
modation.— The  power  which  the  eye  possesses  of  bring- 
ing to  a  focus  on  the  retina  rays  of  different  directions,  is 


ANOMALIES    OF    REFRACTION.  2(51 

termed  accommodation.  By  this  power  the  eye  is  able  to 
distinguish  clearly  objects  at  various  distances.  The  fact 
that  we  are  unable  to  see  distinctly  at  the  same  moment 
near  and  distant  objects,  is  conclusive  evidence  that  there 
must  be  a  focussing  i)o\ver  within  the  eye.  Accommoda- 
tion is  a  muscular  although  an  unconscious  effort,  and 
must  not  be  confounded  with  refraction^  which  is  a  fac- 
ulty possessed  by  all  eyes,  of  bringing  certain  ra^'s  to  a 
focus  on  the  retina  uuthoiit  any  accommodative  effort,  and 
is  dependent  on  the  shape  of  the  globe  and  on  the  media 
within  it.  The  experiments  of  Helmholtz  with  his  oph- 
thalmometer proved  conclusively  that  during  accommo- 
dation for  near  objects,  the  lens,  and  especiall}'  its  ante- 
rior surface,  is  rendered  more  convex  and  approaches  the 
cornea;  and  that  the  pupil  contracts  and  advances  whilst 
the  periphery  of  the  iris  recedes.  The  agent  through 
which  the  change  in  the  lens  is  effected,  is  the  ciliary 
muscle,  but  the  mechanism  by  which  this  is  accomplished 
has  not  yet  been  satisfactoril}^  demonstrated.  The  con- 
traction of  the  pupil  during  accommodation,  Donders  con- 
siders as  probably  only  an  associated  movement.  That 
the  iris  has  no  share  in  the  process  of  accommodation  was 
proved  in  a  case  under  the  care  of  Yon  Graefe,*  where  he 
removed  the  whole  of  the  iris,  and  afterwards  ascertained 
b}'  a  careful  examination,  that  the  eye  still  possessed  a 
range  of  accommodation  which  corresponded  to  the  age 
of  the  patient. 

In  a  normal  eye  distant  objects  are  seen  without  any 
effort  of  the  accommodative  power ;  it  is  only  for  near  ob- 
jects that  there  is  active  accommodation.  This  is  proved 
by  mydriatics — drugs  which  dilate  the  pupil  and  paralj^ze 
the  accommodation.  If  we  drop  into  the  eye  one  or  two 
drops  of  a  solution  of  atropiaj  sulphat.  gr.  4,  ad  aqutii  3  1, 

*  Arcliiv  liir  Ophtliahnologie,  vii,  2. 


262  DISEASES    OF   ACCOMMODATION. 

we  not  oul}'  dilate  the  pupil,  but  in  about  forty  miuutes 
we  paralyze  the  accommodative  power,  that  is,  we  relax 
it  to  its  utmost.  We  then  find  that  the  patient  is  unable 
to  define  clearly  near  objects,  but  distant  vision  is  unim- 
paired. 

An  e3-e  is  said  to  be  normally  constructed  or  emme- 
tropic, when  it  is  able  by  virtue  of  its  own  refractive 
power,  and  without  any  effort  of  the  accommodation,  to 
unite  to  a  focus  on  the  retina  parallel  or  distant  rays. 

There  are  two  ways  in  which  the  refraction  may  differ 
from  that  of  the  emmetropic  eye.  The  axis  of  vision  may 
be  too  long,  so  that  parallel  incident  raj's  are  brought  to 
a  focus  in  front  of  the  retina,  as  in  myopia  ;  or  the  axis 
of  vision  may  be  too  short,  as  in  hypermetropia,  where 
parallel  rays  are  united  behind  the  retina.  We  have  now 
to  consider  in  succession  the  following  conditions  of  the 
eye,  and  the  treatment  Avhich  is  suited  to  each : 

Myopia,  Astigmatism, 

Hypermetropia,       Presb3-opia. 

The  three  first-named  are  anomalies  of  refraction,  as 
the  impairment  of  sight  they  produce  maj^  be  altogether 
independent  of  any  faulty  state  of  the  accommodation. 
Presbyopia,  however,  must  be  regarded  as  a  normal  state 
occurring  in  an  emmetropic  eye  as  a  natural  result  of  in- 
creasing years,  and  without  any  necessary  defect  of  its 
power  of  refraction. 

MYOPIA. 

Myopia,  or  Short  Sight,  is  usually  dependent  on  a  too 
great  length  in  the  antero-posterior  diameter  of  the  globe, 
so  that  the  rays  of  light  coming  from  a  distance  are 
brought  to  a  focus  in  front  of  the  retina,  upon  which  circles 
of  diffusion  are  formed  in  the  place  of  a  clearly-defined 
image,  and  the  object,  therefore,  appears  confused  and 


MYOPIA.  263 

indistinct.  Myopia  ma}^,  however,  be  due  to  a  too  great 
refractive  power  in  the  eye,  without  any  abnormal  increase 
in  the  length  of  the  globe,  as  in  those  exceptional  cases 
of  spasm  of  the  ciliary  muscle,  in  which  an  undue  ro- 
tundity is  given  to  the  lens.  Nearly  all  the  cases  of  my- 
opia are  dependent  on  the  first-mentioned  cause,  and  the 
extension  of  the  antero-posterior  diameter  of  the  globe 
will  be  found  to  arise  from  a  prolongation  of  the  posterior 
half  of  the  eye.  It  is  seldom  that  there  is  any  change 
in  the  diameter  in  the  anterior  or  corneal  half.  This 
increase  in  the  length  of  the  globe  is  usually  accompa- 
nied by  a  thinning  of  the  sclerotic,  and  a  partial  atrophy 
of  the  choroid,  and  is  recognized  by  the  names  Posterior 
Htaphyloma.,  or  Sclerotico-choroiditis  j^osterior.  It  is  usu- 
ally found  in  all  cases  of  severe  myopia.  Graefe  saj^s  that 
it  is  always  present  when  the  myopia  exceeds  ^,  that  is, 
when  a  stronger  concave-glass  than  one  of  five-inch  nega- 
tive focus  is  required  to  correct  it ;  but  a  posterior  sta- 
phyloma will  often  be  seen  in  myopia  as  low  as  y'g  or  ,^^^. 
The  staph^'loma  may  be  a  uniform  prolongation  of  the 
posterior  coats  of  the  eye ;  but  it  is  generally  a  more  or 
less  marked  ovoid,  bulging  between  the  yellow  spot  and 
the  outer  margin  of  the  optic  disc.  The  great  length  of 
a  highly  myopic  eye  may  be  usually  seen  b}^  drawing  the 
outer  canthus  away  from  the  globe  with  one  finger,  whilst 
the  patient  is  made  to  look  as  much  inwards  as  possible, 
by  directing  his  attention  to  an  object  on  the  other  side 
of  his  nose. 

Myopic  patients  can  usually  see  clearly  near  objects, 
but  they  are  unable  to  make  out  those  at  a  distance,  and 
in  endeavoring  to  do  so  thej^  instinctivel}^  partially  close 
the  eyelids,  to  diminish  the  palpebral  aperture.  In  this 
manner  they  cut  off  many  of  the  peripheral  rays  which 
emanate  from  the  object  they  are  looking  at,  and  by  thus 


264  DISEASES    OF    ACCOMMODATION. 

limiting  the  circles  of  diffusion  they  obtain  a  more  sharpl}^- 
defined  image. 

Myopia  maybe  hereditary,  congenifal,  or  acquired.  It 
is  generally  hereditary,  but  vot  congenital,  in  that  it  does 
not  usually  manifest  itself  until  after  eight  or  nine  years 
of  age.  Myopia  will  be  often  found  to  have  existed  in 
families  for  many  past  generations.  Acquired  myopia  is 
occasional!}"  seen  in  watchmakers,  steel-plate  engravers, 
and  others,  who  for  many  years  have  l^een  in  the  habit  of 
applj'ing  their  eyes  for  several  hours  daily  to  fine  work, 
or  to  literary  pursuits.  Like  all  other  bodily  defects, 
when  once  acquired  it  may  be  transmitted,  and  so  become 
hereditary.  No  doubt,  to  insure  this  result,  it  is  neces- 
sary that  the  eye  should  have  been  specially  nsed  through- 
out several  generations.  M3'opia  may  be  thus  regarded 
as  one  of  the  evils  of  civilization  and  high  mental  cul- 
ture. The  great  demand  which  scientific  and  manufac- 
turing pursuits  make  on  the  eyes,  causes  them  to  gradu- 
ally attain  through  successive  ages  an  increased  growth 
and  development.  Up  to  a  certain  point  this  is  productive 
of  improved  vision  —  of  sight  which  is  good  for  both  near 
and  distant  objects ;  but  beyond  a  fixed  limit  the  eyes 
become  too  large,  and  myopia  is  the  result. 

Ophthalmoscopic  Appearances  op  a  Myopic  Eye. — 
Bi/  direct  examination,  that  is,  by  aid  of  the  mirror  with- 
out the  use  of  the  object  lens,  the  structures  of  the  fundus 
ma}^  be  seen  at  some  inches  from  the  eye,  and  if  the  pa- 
tient be  made  to  move  his  head  in  one  direction,  the  reti- 
nal vessels  will  appear  to  travel  in  the  other,  showing  that 
the  image  which  is  seen  is  inverted.  The  reverse  of  this 
occurs  in  the  direct  examination  of  h3'permetropic  ej'es, 
when  the  parts  at  the  fundus  will  seem  to  move  with  the 
head,  proving  that  the  image  is  erect. 

By  an  indirect  ophthalmoscopic  examination,  that  is, 


MYOPIA.  265 

by  the  aid  of  both  the  mirroi'  and  object  lens,  the  oi:)tic 
nerve  and  vessels  appear  rather  smaller  and  brighter  than 
in  an  emmetropic  eye.  In  most  myopic  eyes,  evidence 
of  a  posterior  staph3'loma  is  seen  in  a  small  white  band 
or  crescent  generally  on  the  apparent  inner  side  of  the 
optic  nerve.  This  is  known  as  the  myopic  arc  or  crescent. 
It  is  caused  by  the  prolongation  backwards  of  the  scle- 
rotic, and  consequent  stretching  of  that  portion  of  the 
choroid  which  corresponds  to  the  staph3doma.  This  ex- 
tension of  the  choroid  induces  atrophj^  and  thinning  of 
its  texture,  so  as  to  render  transparent  that  part  of  it 
which  is  adjacent  to  the  optic  nerve,  and  upon  which  the 
greatest  pull  is  exerted,  and  thus  to  allow  the  white 
shining  surface  of  the  subjacent  sclerotic  to  gleam 
through.  Occasionally  the  choroid  is  completely  de- 
tached around  a  portion  of  the  margin  of  the  optic  nerve. 
The  width  of  the  arc  is  usually  proportioned  to  the  de- 
gree of  the  myopia,  and  in  severe  cases  it  will  sometimes 
extend  entirely  round  the  optic  disc,  or  instead  of  a  cres- 
cent there  will  be  a  large,  white,  irregular  patch,  over 
which  the  retinal  vessels  will  be  seen  coursing.  See  arti- 
cle Sclerotico-Choroiditis  Posterior,  page  220. 

Treatment  of  Myopia. — In  examining  a  mjopic  e^'^e, 
the  points  to  be  decided  are : 

1.  The  degree  of  mj^opia  and  the  range  of  accommo- 
dation. 

2.  Whether  the  myopia  is  stationary  or  progressive. 

3.  Whether  it  is  simple  or  complicated. 

1.  The  Degree  of  Myopia  and  Range  of  Accommoda- 
tion.'^— Note  at  what  distance  from  the  eye  the  patient 

*  The  best  test-types  are  those  prepared  by  Dr.  Snellen,  of 
Utrecht.  They  may  be  obtained  of  "Williams  &  Norgate,  Covent 
Garden,  London. 

23 


2GG  DISEASES    OF    ACCOMMODATION. 

can  read  No.  1.  This  is  his  far  point.  If  it  be  at  fi,  8, 
or  10  inches,  the  myopia  is  termed  ^,  |,  or  j'^,  as  with  a 
concave  lens  of  6",  8",  or  10"  focus,  he  ought  theoreti- 
cally to  be  able  to  see  clearly  distant  objects  ;  practi- 
call}^,  however,  he  will  require  glasses  of  a  lower  focal 
power. 

Next  determine  his  near  jyoinf,  and  this  is  done  bj'  as- 
certaining how  close  to  the  e^'e  he  can  read  the  same 
type ;  the  space  between  the  near  and  far  points  will  in- 
dicate the  range  of  the  accommodation.  Having  pro- 
ceeded so  far,  find  out  b^^  trial  with  successive  glasses 
the  weakest  concave  lens  with  which  the  patient  can  see 
No.  XX  at  20  feet.  If  no  glass  will  bring  his  sight  up 
to  this  standard,  his  acuteness  of  vision  is  impaired,  and 
this  defect  is  due  to  some  other  cause  than  simple  mj^o- 
pia.     See  Complications  of  Myopia,  page  268. 

Each  eye  should  be  tested  separately  by  closing  the 
one  which  is  not  under  examination,  telling  the  patient 
to  place  his  hand  over  it.  If  one  eye  is  more  mj'opic 
than  the  other,  it  is,  as  a  rule,  best  to  give  spectacles  with 
both  glasses  of  the  same  focal  power  as  that  which  is 
suited  to  the  least  short-sighted  eye.  There  are,  however, 
exceptional  cases  where  patients  may  be  allowed  to  wear 
spectacles  with  glasses  of  different  foci  for  the  two  eyes, 
but  it  is  seldom  satisfactoiy.  In  testing  with  glasses, 
each  lens  should  be  placed  as  close  to  the  eye  as  it  would 
be  worn  in  the  spectacle  frame,  as  its  strength  is  in- 
creased if  it  is  held  at  a  distance. 

If  there  is  an  insuflicienc}^  of  the  internal  recti  mus- 
cles, so  that  the  patient  is  unable  to  converge  both  his 
e^^es  on  a  near  object,  and  this  defect  is  not  corrected  by 
the  use  of  glasses,  it  will  be  necessary  to  divide  one  or 
both  of  the  external  recti.  Tlie  external  muscle  of  the 
most  defective  eye  should  be  first  divided,  and  if  after  an 
interval  of  a  few  days  it  is  found  that  the  effect  has  not 


MYOPIA.  267 

been  sutllcient,  a,  similar  tenotomy  should  be  performed 
on  the  other  eye. 

General  Rules  for  the  Selection  of  Glasses. — When  the 
myopia  is  below  ts'q,  no  spectacles  should  be  worn,  but 
the  patient  should  be  furnished  with  glasses  in  a  folding 
frame,  which  he  can  appl}'  to  his  eyes  when  looking  at 
objects  beyond  his  range  of  vision. 

In  low  degrees  of  myopia,  such  as  from  ^'^  to  j'^,  if  the 
accommodation  is  good,  one  glass  will  suffice  for  the  pa- 
tient,'and  with  it  he  will  be  able  both  to  read  and  see 
distant  objects.  But  if  the  accommodative  power  of  the 
eye  is  much  impaired,  the  patient  will  often  require  a 
reading-glass  of  a  low  power.  When  stronger  glasses 
are  required,  as  in  cases  of  myopia  from  about  jV  to  4? 
it  will  be  well  to  give  the  patient  spectacles  with  weak 
lenses  for  reading,  and  stronger  concaves  for  wearing  in 
the  streets  or  when  looking  at  things  at  a  distance. 

In  high  degrees  of  myopia,  as  from  ^  upwards,  the 
patient  should  not,  as  a  rule,  be  allowed  to  wear  con- 
stantly glasses  which  completely  neutralize  the  myopia, 
they  will  often  fatigue  the  eye  and  produce  too  much 
dazzling.  He  should  be  ordered,  for  constant  use,  the 
concaves  which  suit  him  best  for  reading  and  enable  him 
to  see  well  eight  or  ten  feet  in  front  of  him,  and,  in  addi- 
tion, he  should  be  given  a  pair  of  glasses  in  folding  frames, 
of  a  focus  which  will  represent  the  ditlerence  between 
those  he  requires  for  reading  and  distance.  These  he 
ma}^  hold  in  front  of  his  spectacles,  when  looking  at  ob- 
jects beyond  the  power  of  the  glasses  he  has  on ;  thus,  a 
patient  who  requires  —  |  for  distance,  and  —  y\^  for  read- 
ing, may  be  ordered  spectacles  with  —  j%  for  constant 
wear,  and  a  double  eyeglass  with  —  ^  for  occasional  use 
in  front  of  his  spectacles  ;  for  ^  —  .^  =  ^.  If  the  glasses 
dazzle,  or,  if  the  eyes  are  irritable,  much  comfort  may  be 
often  gained  by  ordering  the  lenses  to  be  tinted  with  co- 


268  DISEASES    OF    ACCOMMODATION. 

bait  blue ;   and  this  is  especially  beneficial  if  the  e3'es 
have  to  be  much  used  with  artificial  light. 

2.  Whether  the  3Iyopia  is  stationary  or  progressive. — 
In  most  young  people  the  myopia  is  progressive ;  it  is, 
therefore,  of  the  utmost  importance  that  the  rules  which 
are  given  under  the  heading  of  General  Directions, 
should  be  strict^  followed,  in  order  to  retard,  if  possi- 
ble, its  increase  and  render  it  stationary. 

In  stationary  mj^opia  of  a  low  degree,  the  sight  may 
steadil}'  improve  as  age  advances,  and,  ultimately,  the 
patient  may  be  able  to  discard  the  use  of  glasses,  but  this 
is  rather  exceptional.  In  m3'opia  of  a  high  degree,  there 
is  alwaj's  a  strong  tendency  to  increase.  If  the  progress  is 
rapid,  it  is  usually  accompanied  with  symptoms  of  irrita- 
tion, which  require  careful  management.  The  patient 
complains  of  musca?,  flashes  of  light  and  globes  of  fire  ; 
the  eyes  will  flush  easily  when  reading,  or  often  without 
an  apparent  cause,  and  they  look  red  and  irritable.  With 
si^ch  symptoms,  the  use  of  glasses  should  be  for  a  time 
abandoned,  or  only  those  of  a  low  power  allowed,  suffi- 
cient to  enable  the  patient  to  perform  the  duties  abso- 
lutel}'  required  of  him.  A  leech  to  eaci  temple,  repeated 
ever}'  two  or  three  days,  for  a  few  times,  will  sometimes 
give  great  relief  A  small  blister,  of  the  size  of  a  shil- 
ling, may  also  be  applied  behind  the  ears,  and  repeated 
from  time  to  time,  so  as  to  keep  up  a  little  counter-irrita- 
tion ;  or  some  stimulating  liniment  may  be  used  for  a 
similar  purpose.  The  eyes  may  be  frequently  bathed 
with  a  cold  lotion  (F.  35,  37),  which  may  be  applied  over 
the  closed  lids  with  a  fold  of  linen  when  the  patient  is 
Ij'ing  down.  The  most  important  treatment,  however, 
consists  in  rest  to  the  eyes,  by  abstaining  from  all  work, 
and  especially  that  which  induces  a  stooping  position  of 
the  head. 

3.  Whether  the  Myojna  is  simple  or  covqjlicated. — If 


iMYOPIA.  269 

suitiil)le  concaA'e  glasses  fail  to  make  the  patient  read  No. 
XX,  Snellen,  at  twent}^  feet,  there  is  superadded  to  the 
m3^opia  some  other  defect  to  account  for  his  impairment 
of  vision.  Myopia  may  be  complicated :  1,  with  amblyo- 
pia or  weak  sight,  due  to  defective  sensibility  of  the 
retina;  2,  with  astigmatism ;  3,  with  an  increasing  poste- 
rior staph^doma  and  atrophj^  of  the  choroid  ;  4,  with  de- 
ficienc}^  of  power  of  the  internal  recti  muscles  (muscular 
asthenopia);  5,  with  opacities  of  the  cornea;  6,  with 
opacities  of  the  vitreous ;  7,  with  choroidal  or  retinal 
hemorrhage ;  8,  with  partial  detachment  of  the  retina. 
For  the  treatment  of  all  these  complications,  the  reader 
is  referred  to  the  different  sections  under  which  they  will 
be  found  in  the  index. 

General  Directions  for  Myopic  Patients. — Avoid  all 
stooping  positions  of  the  head,  as  thej'  tend  to  cause  con- 
gestion of  the  ej'es.  In  reading,  sit  with  the  head  thrown 
back,  and  bring  the  book  to  the  e3-es  instead  of  taking 
the  e3'es  to  the  book.  Never,  if  it  can  be  avoided,  read 
books  printed  in  narrow,  double  columns ;  the  having  to 
relax  frequently  the  accommodation,  as  the  eye  travels 
from  one  short  line  to  the  next,  tends  to  induce  fatigue. 
Never  read  in  a  moving  carriage ;  the  repeated  jolts  dis- 
place the  words  on  which  the  eye  is  fixed,  and  tire  the 
eye  hy  requiring  it  to  keep  readjusting  itself.  If  the  ej'es 
grow  fagged  whilst  reading,  rest  awhile,  and  do  not  re- 
sume work  until  the^^  are  refreshed.  Avoid  working  by 
an  artificial  light,  and  especially'  gas  which  flickers.  The 
best  lamps  are  the  so-called  "  reading  lamps,"  provided 
with  a  shade  which  throws  their  light  on  the  object  to  be 
seen,  and  leaA'es  the  rest  of  the  room  in  comparative  dark- 
ness, into  which  the  ej-e  can  roam  when  feeling  fatigued. 
When  the  ej^es  are  tired,  or  hot  and  irritable,  the  best  ap- 
plication is  cold  water,  with  which  the  eyes,  the  lids  be- 
ing closed,  may  be  bathed;    or  a  gentle  stream  of  cold 

23* 


270  DISEASES    OF   ACCOMMODATION. 

water  may  be  carried  against  the  closed  lids  by  means  of 
the  siphon  eye-doiiche. 

Hypermetropia  is  the  reverse  of  myopia ;  for  whereas 
in  myopia  the  optic  axis  was  too  long,  and  parallel  ra^s, 
or  those  emanating  from  distant  objects,  were  brought  to 
a  focus  in  front  of  the  retina,  in  hypermetropia  the  antero- 
posterior diameter  is  too  short,  and  the  focal  point  of  par- 
allel rays  is  behind  the  retina.  The  result  of  this  defect 
is  that  only  convergent  raj'S  can  be  brought  to  a  focus  on 
the  retina.  The  h3^permetropic  eye.  is  conseqnentl}'  un- 
able to  receive  correct  impressions  of  things  at  a  distance 
when  in  a  state  of  repose,  that  is,  with  its  accommodation 
relaxed,  but  it  has  to  bring  into  action  its  focussing  power, 
in  order  to  converge  sufficiently'  the  parallel  ra^'s.  The 
strain  on  the  accommodation  is  therefore  in  proportion 
to  the  nearness  of  the  object. 

Adopting  Donders's  classification,  h3-permetropia  may 
be  diA'ided  into  acquired  and  original.  The  acquired  is 
occasionally  met  with  in  old  people,  generally  above  60 
or  70  3'ears  of  age,  when  it  is  associated  with  presbyopia. 
Hj^permetropia  may  thus  be  often  found  in  an  originally 
emmetropic  eye.  The  patient  not  only  requires  convex 
glasses  for  reading  and  looking  at  near  objects,  but  the 
refractive  power  of  the  eye  has  become  so  reduced  that 
he  also  needs  convex  glasses  for  distance.  Another  form 
of  acquired  hjqoermetropia  is  found  in  cases  of  what 
Donders  calls  "  aphakia,"  or  absence  of  the  lens  from  the 
dioptric  system  of  the  eye..  This  may  occur  from  ex- 
traction of  the  lens  for  cataract,  or  from  a  dislocation  of 
the  lens  out  of  the  field  of  vision  from  an  accident.  In 
both  of  these  cases  convex  glasses  are  required  for  dis- 
tance. 

Original  hypermotrojva  ma}'  be  said  to  exist  in  two 
states,  the  manifest  and  the  latent. 


HYPERMETROPIA.  271 

The  manifest  is  that  degree  of  hypermetropia  wliich 
the  patient  exhibits  before  the  accommodation  has  been 
paralyzed  with  atropine. 

The  latent  is  the  amount  of  hypermetropia  which  is 
found  after  the  accommodation  has  been  paralyzed  with 
atropine,  and  which  was  not  manifest  so  long  as  the 
patient  exerted  his  focussing  power  in  looking  at  distant 
objects. 

Donders  further  divides  h3'permetropia  ijito  absulute, 
relative^  and  factiUative. 

Absolute  is  when  the  e3'e  can  neither  read  fine  print, 
nor  tell  clearly  distant  objects.  With  the  strongest  con- 
vergence of  the  eyes  the  patient  cannot  accommodate  for 
parallel  rays.  This  form  is  seldom  met  with  in  the  young, 
as  with  them  there  is  nearly  always  a  certain  amount  of 
accommodative  power,  which  enables  them  to  overcome 
a  portion  of  the  hypermetropia. 

Relative  hypennetropia  is  when,  in  order  to  see  clearly 
a  near  object,  say  at  a  distance  of  sixteen  inches,  the  eyes 
are  obliged  to  converge  as  if  looking  at  one  at  twelve 
inches.  The  patient  can  only  accommodate  for  the  real 
point,  by  converging  the  visual  lines  to  another  point 
nearer  to  the  eyes ;  in  fact,  by  giving  to  them  a  periodic 
convergent  squint. 

Facultative  hypermetropia  is  when  the  patient  can  see 
clearly  distant  objects,  cither  with  or  without  convex 
glasses,  and  he  can  also,  with  an  effort  which  is  almost 
unperceived,  read  and  write  Avell,  but  the  eyes  are  spe- 
cially liable  to  suffer  from  asthenopia,  when  called  upon 
to  perform  much  continuous  close  work.  Such  eyes  also 
soon  become  presbyopic. 

Treatment  of  Hyj^ermefropia. — Find  out  the  degree  of 
hypermetropia,  and  then  furnish  the  patient  with  such 
glasses  as  will  best  remedy  his  defect. 

To  ascertain  the  degree  of  Hypermetropia. — First  direct 


272  Di.-EASES  or  accommodation. 

the  patient  to  look  at  Xo.  XX,  at  20  feet  distance,  and 
find  out  the  strongest  convex  gkiss  with  which  he  can 
clearl}'  make  out  that  t^pe.  The  strength  of  the  lens  will 
indicate  the  degree  of  manifest  hypermetropia :  thus  if  an 
eighteen  or  twentj'-inch  focus  convex  glass  be  required, 
the  patient  is  said  to  have  a  manifest  hypei'metropia  of 
^'g  or  tt'q.  He  should  then  be  directed  to  read  Xo.  1,  with 
this  glass,  and,  if  he  can  do  so  with  facilitj',  he  may  be 
allowed  a  pair  of  spectacles,  with  lenses  of  the  same 
focus,  for  constant  use ;  but  if  he  should  be  unable  to  see 
the  type,  or  orAy  to  make  it  out  with  difficult}',  stronger 
glasses  should  be  tried  in  succession  until  the  ej^es  are 
suited.  The  spectacles  which  are  thus  furnished  to  the 
patient  will  probably,  however,  only  suffice  him  for  a  time, 
as  they  do  not  neutralize  his  latent  h^-permetropia,  and 
this  will  gradually  become  manifest  as  the  patient,  by  the 
aid  of  his  glasses,  ceases  to  strain  his  accommodation  for 
distance.  After  a  time  he  wdll  probably',  therefore,  require 
stronger  glasses.  In  low  degrees  of  hypermetropia,  for 
l)ractical  purposes  this  examination  may  be  sufficient, 
and  suitable  glasses  may  be  thus  given  to  the  patient ; 
biit  in  all  severe  cases  the  amount  of  latent  hypermetropia 
should  also  be  ascertained.  To  do  this,  the  accommoda- 
tion of  the  eye  should  be  first  paralj^zed  by  dropping  into 
it  a  few  drops  of  a  solution  of  atropine  gr.  4  ad  aquje  s  1 ; 
and  when  the  full  effect  has  been  gained,  tr}-  what  convex 
glass  will  enable  the  patient  to  see  Xo.  XX  at  20  feet. 
Xow,  an  ordinary  emmetropic  eye,  thus  treated,  would 
be  able  to  read,  unaided  b}'  glasses,  Xo.  XX  at  20  feet, 
for  without  ajiy  effort  of  accommodation  it  can  unite  par- 
allel rays  on  the  retina;  but  the  hj^permetropic  eyQ  will 
neeel  a  convex  lens,  and  one  of  a  greater  power  than  that 
which  was  called  for  before  the  instillation  of  the  atro- 
pine. The  focal  power  of  the  lens  now  required,  will  give 
the  degree  of  latent  hypermetropia.    As  a  rule  the  patient 


HYPERMETROPIA.  273 

cannot  wear,  constantly,  glasses  of  the  strength  necessary' 
to  neutralize  the  latent  h3pernietropiai  as,  from  having 
been  long  accustomed  to  use  unconsciously  his  accommo- 
dation for  distance,  he  is  unable  to  completely  relax  it, 
and  strong  convex  glasses  would  confuse  and  fatigue  the 
eye.  He  should  therefore  first  be  ordered  weaker  glasses, 
and  these  may  be  changed  from  time  to  time  for  stronger 
ones,  as  may  be  necessary. 

Peculiarities  of  the  Hijpemnetroinc  Eye. — It  is  smaller 
in  all  its  dimensions  than  the  emmetropic  eye,  but  espe- 
cially in  the  antero-posterior  diameter,  so  that  the  globe 
ha«  a  flattened  appearance.  This  can  be  distinctly  seen 
if  the  patient  is  directed  to  look  as  far  inwards  as  possible 
whilst  the  outer  canthus  is  drawn  outwai'ds  with  one  finger. 
It  will  then  be  noticed  that  the  curve  of  the  e3e  over  which 
the  external  rectus  curls  to  its  insertion  is  short  and  ab- 
rupt, and  that  the  globe  looks  flat  and  small  for  the  orbit. 
Bonders  says :  "  The  h3'permetropic  eye  is  in  general  an 
imperfectly  developed  eye.  If  the  dimensions  of  all  the 
axes  are  less,  the  expansion  of  the  retina  also  is  less,  to 
which,  moreover,  a  slighter  optic  nerve  and  a  less  number 
of  its  fibres  correspond."*  Ilxamined  with  the  ophthal- 
moscope, an  erect  image  of  the  fundus  of  the  hA'perme- 
tropic  eye  can  be  seen  with  the  mirror  without  the  use  of 
the  object  lens,  and  on  the  patient  moviug  his  head  the 
retinal  vessels  will  be  seen  to  travel  in  the  same  direction. 

Hypermetropia  is  very  hereditary  ;  many  members  of  a 
family  of  which  one  or  both  the  parents  are  hyperme- 
tropic, are  frequently  found  also  to  suffer  from  this  defect 
of  the  e^es. 

Reaults  of  Hypermetropia. — It  is  the  most  frequent 
cause  of  convergent  strabismus,  and  of  asthenopia  or  weak 
sight. 

*  Duiidcrs  on  the  Acconiniodatiun  and  Refraction  of  the  Eye, 


274  DISEASES    OF    ACCOMMODATION. 


PRESBYOPIA. 

Presbyopia  or  Long  Sight  is  one  of  the  first  of  the 
legion  of  troubles  which  advancing  j-ears  bring  npon  all 
of  us.  In  true  presbj^opia  the  near  point  is  removed  from 
the  eye,  but  distant  vision  is  unimpaired.  The  first  inti- 
mation the  patient  has  of  commencing  presbAopia  is  that 
the  type  which  he  could  once  see  clearly  at  from  eight  to 
twelve  inches,  is  now  indistinct,  and  in  order  to  read  it, 
he  is  obliged  to  hold  the  book  at  a  greater  distance.  As 
presbyopia  advances,  the  failure  of  sight  for  near  objects 
increases,  and  this  is  especially  noticeable  in  the  evening, 
when  the  patient  seeks  a  strong  light  to  work  by,  because 
Avith  it  the  pupil  contracts  and  the  circles  of  diffusion  are 
rendered  smaller. 

Presbyopia  is  caused  by  a  diminished  power  of  accom- 
modation, and  probablv  also  b}'  senile  changes  in  the 
structure  of  the  lens.  It  creeps  on  imperceptibh^,  the 
near  point  being  gradualh'  removed  from  the  eye  as  age 
advances,  until  the  patient  is  unable  to  discern  any  small 
objects  without  the  aid  of  convex  glasses.  Bonders  sa^s  : 
"  The  term  presb3opia  is,  therefore,  to  be  restricted  to 
the  condition,  in  which,  as  the  result  of  the  increase  of 
years,  the  range  of  accommodation  is  diminished,  and 
the  vision  of  near  objects  is  interfered  with."  It  is,  he 
remarks,  "  no  more  an  anomal}-  than  are  gray  hairs  or 
wrinkling  of  the  skin."* 

Treatment  of  Presbyopia It  is  a  question  often  asked, 

when  ought  convex  glasses  first  to  be  used  ?  Bonders 
says :  "  So  soon  as,  by  diminution  of  accommodation,  in 
ordinary  work,  the  required  accuracy"  of  vision  begins  to 
fail,  there  is  need  of  convex  glasses.     The  test  is,  that 

*  Donders  on  the  Accommodution  and  Ecfraction  of  the  Eye, 
p.  'ilU. 


ASTIGMATISM.  275 

with  weak  glasses  of  from  ^'g  to  ^'^j  at  the  same  distance 
as  without  glasses,  the  accuracy  of  vision  is  manifestly 
improved."*  It  is  an  error  to  suppose  that  presbyopic 
patients  should  postpone  the  use  of  glasses  for  as  long  a 
period  as  possible.  By  so  doing  they  subject  themselves 
to  an  amount  of  discomfort  which  could  be  avoided,  and 
without  any  advantage  to  compensate  for  the  sense  of 
fatigue,  heat,  and  occasional  redness  of  the  eyes  which  an 
overstrained  effort  of  the  accommodation  induces. 

In  selecting  glasses  for  presbyopic  patients,  those  should 
be  chosen  which  enable  him  to  read  with  ease  No.  1,  at 
about  ten  or  twelve  inches  from  the  eye.  If  stronger 
glasses  are  given,  they  are  apt  to  induce  fatigue.  When 
convex  glasses  are  first  called  for,  it  will  generally'  only 
be  necessary  to  wear  them  in  the  evening,  as  by  day  the 
patient  will  be  able  to  perform  all  his  duties  without  their 
aid.  But  soon  he  will  take  to  his  glasses  by  day,  and 
then  a  pair  of  stronger  ones  will  be  required  for  evening 
use.  Whenever,  therefore,  he  has  to  increase  the  power 
of  his  glasses,  he  should  take  his  evening  pair  into  day 
use,  and  obtain  stronger  ones  for  his  evening's  work. 

ASTIGMATISM. 

Astigmatism.  —  "  Ametropia,"  says  Donders,  "  com- 
prising the  lesions  of  refraction,  is  resolved  into  two  op- 
posite conditions :  myopia  and  hypermetropia.  Every 
lesion  of  refraction  belongs  to  one  of  these  two.  Some- 
times, however,  it  happens  that,  in  the  several  meridians 
of  the  same  eye^  the  refraction  is  very  different.  In  one 
meridian  the  same  eye  may  be  emmetropic,  in  the  other, 
ametropic ;  in  the  several  meridians  a  difference  in  the 
degree,  and,  even  in  the  form  of  ametropia,  ma}^  occur."f 

*  Donders  on  the  Accommodation  and  Refraction  of  the  Eye, 
p.  217. 

t  Ibid.  p.  449. 


276  DISEASES    OP   ACCOMMODATION. 

This  defect,  dependent  on  a  want  of  symmetry  of  the 
meridians  of  the  eye,  has  been  termed  astigmatism.  The 
exi)hination  of  this  anomaly  is  the  following:  the  cornea 
in  a  nornial  e^'e  is  a  segment  of  an  ellipsoid,  and,  as  its 
horizontal  and  vertical  axes  are  of  different  lengths,  it 
follows  that  its  curvatures  in  these  directions  must  also 
differ;  and  that  vertical  and  horizontal  rays  falling  upon 
such  a  surface,  must  be  unevenly  refracted,  and,  there- 
fore, unite  into  two  separate  foci.  As  a  rule,  the  vertical 
meridian  has  a  shorter  focal  distance  than  the  horizontal. 
Hence,  it  is  that,  in  most  eyes,  vertical  and  horizontal 
lines  are  not  seen  with  equal  clearness  from  the  same 
point  and  at  the  same  time. 

So  far,  astigmatism  may  be  considered  a  natural  defect, 
due  to  a  difference  of  the  vertical  and  horizontal  curva- 
tures of  the  cornea,  and  which,  in  a  minor  degree,  is  com- 
mon to  all  eyes.  It  is  only  when  there  is  a  marked  asym- 
metry between  the  meridians  of  the  cornea,  that  it  at- 
tracts notice,  and  calls  for  the  aid  of  cylindrical  glasses. 

There  are  two  distinct  forms  of  astigmatism :  the  ir- 
7'egidar  and  the  7-egular. 

Irregular  Astigmatism. — Bonders  divides  this  form 
into  normal  and  abnormal. 

a.  Normal  irregular  astigmatism  is  due  to  a  peculiarity 
in  the  structure  of  the  lens.  The  principal  phenomenon, 
he  says,  attending  this  irregularity,  is  monocular  poly- 
opia. This  midtiplication  of  the  object  is  to  be  explained 
by  there  being,  from  some  cause,  an  aberration  of  the 
rays  as  they  pass  through  the  diff'erent  sectors  of  the 
lens,  and  consequently  ''an  imperfect  coincidence,  even 
after  accommodation,  of  the  images  of  the  different  sect- 


*  Donders  on  the  Accommodation  and   Refraction  of  the  Eye, 
p.  518. 


ASTIGMATISM.  277 

/?.  Abnormal  irregular  oMigmatism  may  arise  from  some 
defect  of  either  the  cornea  or  lens. 

From  the  Cornea. — We  have  examples  of  this  form  of 
irregular  astigmatism  in  conical  cornea;  occasionally 
after  the  extraction  of  cataract,  and  after  corneal  ulcera- 
tions. 

From  the  Lens. — Irregular  astigmatism  may  be  caused 
either  by  a  change  in  the  structure  of  the  lens,  as  is  some- 
times seen  in  the  early  formation  of  cataract,  or  by  its 
displacement,  as  in  cases  of  partial  dislocation  of  the 
lens  into  the  anterior  chamber  or  vitreous. 

Regular  Astigmatism  is  due  to  a  difference  in  the 
focal  lengths  of  the  meridians  of  the  eye,  and  is  to  be 
corrected  by  proper  cylindrical  glasses.  It  is  with  this 
form  that  we  have  now  to  deal. 

Regular  astigmatism  may  be  acquired  and  congenital. 
The  acquired  may  be  produced  by  perforating  wounds  of 
the  ejre,  and  especially  those  which  are  near  the  margin 
of  the  cornea ;  thus  it  is  occasionally  met  with  after  the 
operations  of  iridectomy  and  extraction  of  cataract. 
Ulcerations  of  the  cornea  usually  give  rise  to  irregular 
astigmatism ;  a  case,  however,  is  related  by  Bonders,  in 
which,  after  a  perforating  ulcer  of  the  cornea,  the  astigmat- 
ism was  sufficiently  regular  to  be  corrected  by  a  cylin- 
drical glass. 

Regular  Astigmatism  may  be  divided  into: 

1.  Simple  astigmatism^  that  is,  when  one  meridian  is 
emmetropic,  and  the  other  either  hypermetropic  or  my- 
opic. 

2.  Compound  astigmatism,  when  both  meridians  are 
either  myopic  or  h3'permetropic ;  but  the  defect  in  one 
meridian  is  greater  than  in  that  of  the  other;  thus,  if  the 
case  is  one  of  compound  mj-opic  astigmatism,  in  the  hori- 

24 


278  DISEASES    OF   ACCOMMODATION. 

zontal  meridian,  the  myopia  may  be  5'^,  whilst  iu  the 
vertical  it  may  be  j'^. 

3.  3Iixed  astigmatism,  that  is,  where  there  is  hyperme- 
tropia  in  one  meridian  and  myopia  in  the  other.  Such 
cases  are  rare. 

To  ascertain  the  Presence  of  Astigmatism. — First  test 
the  patient's  eyes  with  spherical  glasses,  and  determine 
whether  they  are  mj'opic  or  hypermetropic,  and  if  either, 
what  glasses  most  nearl}'  neutralize  his  defect  of  sight. 
Having,  however,  failed  to  restore,  b}''  glasses,  his  acute- 
ness  of  vision,  the  question  is  whether  his  impairment  of 
sight  is  due  to  astigmatism  or  to  other  causes.  To  find 
this  out,  place  at  one  end  of  the  room  a  set  of  thick, 
vertical,  and  horizontal  lines,  and  let  the  patient  walk  to- 
wards them,  and  stop  the  moment  either  of  them  becomes 
distinct.  If  he  can,  at  a  certain  point,  see  clearly  one  set 
of  lines,  whilst  the  others  are  cloud}^  and  blurred,  he  is 
astigmatic.  A  similar  conclusion  may  be  drawn  if  the 
patient  be  made  to  look  at  a  point  of  light  through  a  per- 
foration in  a  metal  screen  at  a  distance  of  15  feet,  when, 
owing  to  the  astigmatic  eye  being  unable  to  unite  accu- 
rately to  a  focus  vertical  and  horizontal  ra^'s,  the  point 
will  appear  dx'awn  out  to  a  vertical  or  horizontal  line,  ac- 
cording to  whether  the  eye  focusses  correctly  the  hori- 
zontal or  vertical  rays. 

The  patient  should  now  l)e  directed  to  look  through  a 
slit  about  jL  of  an  inch  wide  in  a  disc  of  metal,  which  is 
to  be  slowly  rotated  in  front  of  the  eye,  so  as  to  bring 
the  slit  opposite  each  of  the  ditferent  meridians  in  suc- 
cession. If,  in  a  certain  position  of  the  slit,  he  is  able  to 
make  out  Xo.  XX  at  20  feet,  the  case  is  one  of  simjde 
af!tigmatism.  The  e3'e  is  emmetropic  in  one  meridian  and 
myopic  or  hjpermetropic  in  the  other. 

The  patient  ma}'  then  be  tried  with  a  weak  cylindrical 
convex  or  concave  lens,  which  he  must  rotate  in  front  of 


ASTIGMATISM.  279 

the  ej'e,  until  he  places  the  axis  in  that  direction  which 
gives  him  the  most  correct  vision.  Should  the  glass  first 
tried  not  quite  answer,  others  of  a  slightly  higher  or  lower 
focal  power  may  be  held  up  in  turn,  until  the  eye  is  suited. 
Si)ectacles,  with  similar  cylindrical  glasses,  may  be  then 
given  to  the  patient ;  but  in  ordering  them,  the  instruc- 
tions given  below  should  be  followed. 

Comjyound  Astigmatism. — First  ascertain  the  concave 
or  convex  glass,  according  to  whether  the  patient  is  my- 
opic or  hypermetropic,  which  most  improves  vision ;  and 
whilst  he  holds  this  before  his  eye,  place  in  front  of  it  a 
cjdindrical  glass  of  similar  curvature  but  of  low  power, 
and  slowly  rotate  it,  until  the  axis  of  the  cylinder  is  in 
the  right  direction.  If  this  glass  fails  to  afford  the  re- 
quired improvement,  try  other  cylindricals  in  succession, 
until  the  one  which  gives  the  greatest  benefit  has  been 
selected.  For  convenience  of  testing  the  spherical  and 
cylindrical  glasses  together,  a  double  spectacle-frame 
should  be  used,  in  which  the  spherical  lens  should  be 
placed  next  the  eye,  and  the  cylindrical  outside,  so  that 
it  can  be  easil}^  rotated  with  the  finger.  Each  e3-e  should 
be  tried  separately,  the  hand  being  placed  over  the  one 
which  is  not  under  examination.  Having  selected  the 
combination  of  spherical  and  cylindrical  glasses,  direc- 
tions should  be  sent  to  the  optician  to  furnish  the  patient 
with  spectacles  with  the  proper  spherico-cjdindrical  lenses. 
In  the  written  instructions  given  to  the  optician,  the  focal 
power  of  each  glass  should  be  separately  noted,  and  the 
direction  in  which  the  axis  of  the  cylindrical. glass  is  to 
be  worn,  marked  by  the  sign  of  an  arrow.  It  should  be 
also  mentioned  that  the  spherical  face  of  the  lens  is  to  be 
l)laced  next  the  eye.  The  glasses  should  be  fitted  in 
frames  with  circular  eye-pieces,  so  that  the  axis  of  each 
may  be  accurately  adjusted  to  the  e3e  before  the  frames 
are  screwed  up. 


280  DISEASES    OF    ACCOMMODATION. 

Mixed  Astigmatism. — For  the  relief  of  this  form,  hi- 
C3iindrical  glasses  will  be  required.  Find  out  the  couvex 
piano-cylindrical  lens  which  will  neutralize  the  hyperme- 
tropia  in  the  one  meridian,  and  then  the  concave  piano- 
cylindrical  which  will  correct  the  myopia  in  the  other 
meridian.  Place  now  the  two  lenses  in  a  double  spec- 
tacle frame,  with  the  axis  of  the  C3'linders  at  right  angles 
to  each  other,  and  rotate  the  two  together  in  front  of 
the  ej'^e,  so  as  to  ascertain  in  what  direction  of  the  axis 
the  patient  has  the  best  sight.  Having  decided  these 
points,  similar  lenses  may  be  ordered  to  be  united  by 
Canada  balsam,  or  a  similar  bi-cylindrical  glass  may  be 
ground  by  the  optician. 

ASTHENOPIA. 

Asthenopia  or  Weak  Sight  is  a  sj-mptom  due  to 
several  affections  of  the  ej-e.  The  patient  complains  that 
reading,  writing,  or  the  maintenance  of  fine  work  which 
requires  a  close  application  of  the  ej'es,  induces  fatigue ; 
that  when  thus  engaged  the  object  becomes  dim  and  con- 
fused, and  sometimes  suddenly- disappears  ;  that  if  he  rests 
his  eyes  for  a  few  minutes,  he  is  able  to  resume  his  work, 
but  in  a  short  time  he  is  again  obliged  to  desist  from  a 
recurrence  of  similar  sjniptoms. 

Asthenopia  maj'  depend — 1,  on  hypermetroiaia ;  2,  on 
an  insufRcienc}^  of  power  of  the  internal  recti,  which  ren- 
ders a  prolonged  convergence  of  the  eye  difficult  and  some- 
times impossible. 

1.  Asthenopia  due  to  hypermetropia,  is  called  also  ac- 
commodative  Asthenopia.  It  arises  from  the  excessive 
strain  on  the  accommodation  which  the  hypermetropic 
eye  has  to  exert  to  focus  the  diverging  rays  of  near  ob- 
jects. Fatigue  is  consequently  soon  induced,  the  accom- 
modative eflbrt  is  first  partially  relaxed,  and  the  object 


ASTHENOPIA.  281 

under  attention,  being  thrown  out  of  focus,  becomes  con- 
fused and  dim  ;  in  a  few  minutes  all  elTort  of  accommoda- 
tion is  suspended  and  the  impression  is  lost.  After  a 
short  rest  the  patient  can  resume  his  work,  but  the  recur- 
rence of  the  same  confnsion  of  sight  soon  compels  him  to 
give  up  and  to  cease  from  his  employment. 

Treatment. — Properly  fitted  convex  glasses  for  reading, 
writing,  sewing,  or  all  close  work.  (See  Hypermetropia, 
p.  3T0.)  This  form  of  asthenopia  is  often  much  increased 
by  anaemia  and  debility.  In  such  cases  tonics,  and  espe- 
cially^ the  preparations  of  iron,  are  of  great  service  and 
should  be  prescribed  (F.  65,  66). 

2.  Asfhenojna  from  inHufficiency  of  the  internal  recti, 
so  frequently  met  with  in  mj^opia,  is  called  muscular 
asthenopia,  to  distinguish  it  from  the  jDrecediug  form.  It 
is  due  to  a  want  of  sufficient  power  in  the  internal  recti 
to  maintain  a  steady  and  prolonged  convergence  of  the 
eyes  on  a  near  object.  The  patient  complains  that  after 
reading  for  a  short  time  the  letters  become  confused,  and 
the  lines  seem  to  overlap  or  run  into  one  another.  This 
is  caused  by  a  relaxation  of  one  of  the  internal  recti  and 
a  consequent  eversion  of  the  ej'e,  giving  rise  to  slight 
diplopia.  Even  when  these  S3'mptoms  are  absent,  the 
great  effort  which  is  required  to  maintain  convergence 
when  there  is  an  excess  of  power  in  the  external  recti 
muscles  induces  such  an  amount  of  fatigue  and  aching  of 
the  eyes  as  to  compel  the  patient  to  give  up  work. 

To  ascertain  if  there  is  an  insufficiency  of  the  internal 
recti,  direct  the  patient  to  look  at  the  end  of  your  finger, 
which  is  to  be  held  at  ten  or  twelve  inches  from  his  ejes, 
and  then  slowly  approach  it  towards  them,  telling  him  to 
continue  looking  fixedly  at  it  as  it  draws  nearer.  If  there 
is  an  insufficiency,  the  eyes  will  be/ unable  to  maintain  the 
necessary  convergence  as  the  finger  advances  to  within 
six  inches,  and  one  of  them  will  first  waver  and  then 

24* 


282  STRABISMUS. 

gradually  roll  outwards.  Sometimes  this  eversion  of  the 
e3'e  is  almost  spasmodic,  so  quick  and  sudden  is  its  move- 
ment. Often  in  such  cases  there  is  a  difference  in  the 
focal  power  of  the  two  eyes,  and  then  the  one  which  de- 
viates is  the  more  m3'opic,  or,  in  other  respects,  the  more 
defective  of  the  two.  The  degree  of  insufficiency  of  the 
internal  recti  muscles  may  be  accurately  tested  by  the 
means  of  prisms.  (See  article  on  this  subject,  page  299.) 
If  after  a  careful  examination  there  is  found  to  be  such  an 
insufficiency  of  the  internal  recti  muscles,  that  the^^  are 
unable  to  maintain  a  joint  and  prolonged  convergence  of 
the  e3'es  for  near  objects,  the  external  rectus  of  one  or 
both  ej'es  should  be  divided.  It  is  best  to  divide  one  at 
a  time,  unless  the  insufficiencj'  is  very  marked,  and  the 
eye  to  be  selected  for  the  first  operation  should  be  the  one 
which  is  the  more  defective  and  generall}'  Manders  out- 
wards. The  external  rectus  of  the  other  eye  can  be  after- 
wards divided  if  the  effect  gained  by  the  first  operation  is 
not  sufficient. 


CHAPTER  YII. 

STRABISMUS. 

Bonders  defines  strabismus  as  "  a  deviation  in  the 
direction  of  the  eyes,  in  consequence  of  which  the  two 
yellow  spots  receive  images  from  different  objects."* 

Strabismus  may  be  either  convergent  or  divergent ;  it 
is  seldom  that  the  deviation  is  solely  upwards  or  down- 
wards. 

In  most  cases  there  is  a  preponderance  of  power  in 

*  Bonders  on  the  Accommodation  and  Kefraction  of  the  Eye, 
p.  291. 


STRABISMUS.  283 

either  the  internal  or  external  rectus  muscle,  so  that  the 
balance  between  them  is  destroyed,  and  the  ability  to 
steady  the  two  eyes  simultaneousl3'  on  an  object  is  lost. 
Whenever  an  attempt  is  made  to  look  at  a  given  point,  one 
e^^e  rolls  either  inwards  or  outwards  according  to  whether 
the  squint  is  convergent  or  divergent ;  the  optic  axes  are 
no  longer  parallel,  and  the  impressions  of  the  image  fall 
on  different  parts  of  the  two  retinae. 

Monocular  strabisvms  is  when  the  deviation  is  constant 
in  the  one  eye.  It  is  generally  associated  with  impair- 
ment of  sight  in  the  squinting  eye. 

Alternating  or  binocular  strabismus  is  when  the  devia- 
tion occurs  alternately,  first  in  one  eye  and  then  in  the 
other.  The  patient  can  "fix"  with  either  eye,  but  is  un- 
able to  direct  the  two  together  towards  the  same  point. 
When  one  eye  is  fixed,  the  other  rolls  inwards,  and  vice 
versa.  In  alternating  strabismus  the  sight  of  the  two 
eyes  is  nearly  equal. 

Strabismus  ma}^  be  either  peiHodic  or  jpersistent. 

A  ]3eriodic  squint  comes  on  only  at  times,  as  when  the 
patient  is  reading  or  looking  fixedly  at  an  object,  or  after 
the  eyes  have  been  fatigued.  It  may  be  caused  by  some 
eccentric  irritation,  as  from  ascarides,  or  from  dentition, 
but  in  the  large  majority  of  cases  it  is  due  to  hjperme- 
tropia.  A  periodic  squint  may  be  occasionally  benefited 
by  judicious  treatment;  but  more  frequently  the  strabis- 
mus increases,  and  ultimately  becomes  persistent. 

For  ti'eatment  of  periodic  squint,  see  page  289. 

The  Ilouements  of  the  Squinting  Eye. — In  some  cases 
there  is  an  actual  limitation  of  movement  in  the  squinting 
eye,  and  its  range  outwards,  if  the  squint  is  convergent,  or 
inwards  if  it  is  divergent,  is  impeded.  This  may  be  due 
either  to  an  acquired  increase  of  power  in  the  squinting 
muscle,  as  in  some  cases  of  hypermetropia  ;  or  it  may  be 
caused  by  a  loss  of  power  in  the  antagonistic  muscle,  as  in 


284  STRABISMUS, 

m3^opia,  where  there  is  frequently  an  external  strabismus 
consequent  on  an  insufliciency  of  the  internal  recti,  or  as 
in  cases  of  paralytic  squint. 

Generall}^,  however,  the  range  of  action  of  the  squint- 
ing eye  is  not  limited,  but  displaced,  and  this  is  especially 
noticeable  when  the  sight  of  the  two  eyes  is  equal,  and 
the  squint  alternates.  Thus,  before  an  operation  for  an 
internal  strabismus,  the  space  over  which  the  eyes  move 
may  be  three-quarters  of  an  inch;  after  the  operation  the 
range  may  still  be  the  same,  but  it  will  be  transposed,  and 
although  the  e3'e  will  travel  over  no  greater  distance  than 
before,  yet  it  will  be  enabled  to  go  more  outwards,  and 
consequently  less  inwards. 

Strabismus  may  be  induced,  1st,  by  some  anomaly 
in  the  refraction  of  the  e3^es,  as  in  hypermetropia  and 
myopia ;  2d,  from  defective  sight  in  one  eye.  AVhatever 
cause  prevents  binocular  vision  tends  to  produce  squint, 
no  matter  whether  it  be  from  great  differences  in  the  re- 
fraction of  the  two  eyes  as  from  ambljopia,  or  from  opa- 
cities of  the  cornea ;  3d,  strabismus  may  be  produced  by 
paralysis  of  one  or  more  of  the  nerves  supplying  the 
muscles  of  the  eye. 

To  ascertain  and  note  the  extent  of  the  strabismus^  the 
patient  should  be  first  told  to  look  at  an  object  about 
twenty  inches  distant,  when  it  will  be  found  that  whilst 
he  "fixes"  with  one  e^-e,  the  other  rolls  either  inwards  or 
outwards,  as*  the  squint  nuxy  be.  A  mark  is  then  to  be 
made  with  a  pen  on  the  edge  of  the  lower  lid  of  the  squint- 
ing e3'e  opposite  the  centre  of  the  pupil.  The  sound  eye 
must  now  be  covered  with  the  hand,  and  the  patient  di- 
rected to  look  at  the  object  with  the  squinting  eye,  and 
the  position  of  the  centre  of  the  pupil  is  again  to  be 
marked  on  the  edge  of  tlie  lower  lid.  The  space  between 
these  lines  will  indicate  the  deuree  of  the  strabismus : 


STRABISMUS.  285 

thus  we  speak  of  a  strabismus  of  1'",  2"',  or  more, 
according  to  the  interA-al  between  tlie  markings  on  the 
lid.  The  movement  which  the  squinting  e3-e  makes  when 
the  sound  eye  "fixes"  upon  an  object,  is  termed  the 
primary  deviation. 

TJie  secondary  deviation  is  the  extent  of  movement  the 
sound  eye  makes  when  excluded  b^^  the  hand,  whilst  the 
squinting  eye  fixes  itself  on  the  object.  The  strabismus 
is  said  to  be  concomitant  v^hen  the  primarj^  and  secondary 
deviations  are  equal.  The  squinting  eye  is  not  fixed,  but 
follows  the  other  in  its  movements. 

The  plan  adopted  by  Mr.  Bowman  for  determining  the 
degree  of  strabismus,  is  the  following:  The  patient  is 
made  to  look  at  a  near  object  held  at  the  extreme  outer 
limit  of  his  field  of  rision,  first  on  one  side,  then  on  the 
other;  and  the  extreme  limit  of  movement  of  each  eyQ 
inwards  and  outwards  is  then  noted  with  reference  re- 
spectively to  the  lower  punctum  and  the  outer  canthus; 
the  pupil  being  the  part  of  the  eye  used  to  mark  the 
movement  inwards ;  the  outer  edge  of  the  cornea  the 
movement  outwards.  In  noting  the  case  on  paper,  the 
diagrams  of  the  position  of  the  two  eyes  should  be  placed 
on  the  same  line,  as  if  facing  the  observer;  that  of  the 
right  eye  on  the  left-hand  side.  The  following  may  be 
taken  as  an  example : 

Fig   28. 

<^     /•  •        >l 

a  5  <^  d 

a,  b,  Right  eye.  c,  d,  Left  ej-e. 

a.  Extreme  range  outwards;  the  outer  edge  of  (he  cornea  fails  to  reach  the  can- 
thus.  6,  Extreme  range  inwards;  the  pupil  passes  bej'ond  the  piinctum.  c,  Kx- 
treme  range  inwards:  the  pupil  does  not  reach  the  punctum.  d,  Extreme  range 
outwards ;  the  outer  edge  of  the  cornea  passes  beyond  the  canthus. 

In  each  case  the  exact  distance  admits  of  being  re- 


286  STRABISMUS. 

corded.  In  this  manner  the  relative  strength  of  the 
internal  and  external  recti  of  the  two  eyes  nia}'  be  esti- 
mated, and  the  resnlt  marked  down  in  a  single  line,  so  as 
to  show,  at  a  glance,  in  which  eye  the  preponderance  of 
power  of  either  muscle  exists. 

The  degree  of  strabismus  ma}^  be  also  carefully  esti- 
mated by  a  "  Strabismometer  "  invented  by  Mr.  J.  Z. 
liaurence.  "  It  consists  of  an  ivory  plate,  moulded  to 
the  conformation  of  the  lower  eyelid,  the  free  border  cor- 
responding to  that  of  the  lid.  This  border  is  graduated 
in  such  a  manner  that,  while  its  centre  is  designated  by 
0,  Paris  lines  and  half  lines  are  marked  off  on  each  side 
of  0.  Attached  to  the  plate  is  a  handle.  The  applica- 
tion of  this  strabismometer  is  obvious.  The  ivory  plate 
is  applied  to  the  lower  eyelid,  the  borders  of  the  two  cor- 
responding. If  the  cornea  is  central,  the  vertical  diame- 
ter of  the  pupil  corresponds  to  0 ;  if  inverted,  to  a  gradu- 
ation on  the  inner  side  of  0;  if  everted,  to  one  on  the 
outer  side  of  0."  * 

Convergent  or  Internal  Strabismus  is  usually  de- 
pendent on  hypermetropia.  In  17  per  cent,  of  the  cases 
of  convergent  strabismus,  Donders  found  that  there  was 
hypermetropia.f  The  explanation  of  this  fact  is  the  fol- 
lowing. Owing  to  the  peculiar  shape  of  the  hypermetropic 
eye,  the  accommodative  powder  is  called  into  constant  ac- 
tion, and,  for  near  objects,  the  strain  is  very  great.  In 
projjortion  to  the  effort  to  accommodate  is  the  degree  of 
convergence  of  the  eye,  so  that  when  a  hypermetropic  eye 
is  looking  at  a  near  object,  it  converges  more  than  a  nor- 
mal or  emmetropic  eye  would  do,  because  the  stress  on 

*  Optical  Defects  of  the  Eye,  by  J.  Z.  Laurence,  p.  107. 
t  Donders  on  the  Accommodation  and  Refraction  of  the  Eye, 
p.  292. 


DIVERGENT   STRABISMUS.  287 

the  accommodation  is  greater.  This  excessive  action 
of  the  internal  recti  muscles  causes  them  to  acquire  in- 
creased strength,  and  gradually  to  preponderate  OA'er 
their  antagonists  the  external  recti,  until  ultimatelj^  a 
convergent  strabismus  is  established. 

In  hyperraetropia  the  strabismus  usually  first  appears 
at  the  time  the  child  begins  to  apply  his  eyes  to  close 
work — as  in  learning  to  read — when  the  efforts  of  accom- 
modation and  convergence  are  brought  into  more  active 
play.  The  degree  of  strabismus  is  not  necessarily  pro- 
portioned to  the  extent  of  the  h3-permetropia.  In  very 
hypermetropic  e^^es  the  sight  is  so  defective,  and  so  little 
benefited  by  any  accommodative  effort,  that  the  patient 
ceases  to  strain  his  eyes,  and  consequently  convergent 
strabismus  is  less  frequent  than  in  eyes  with  a  lower  de- 
gree of  hypermetropia,  where,  b}'  a  strong  endeavor  to 
accommodate,  the  sight  is  materially  improved.  In  hy- 
permetropic strabismus  there  is  frequently  a  considerable 
difference  in  the  refraction  of  the  two  ej-es.  Defective 
vision  in  one  eye,  combined  with  hypermetropia,  but  irre- 
spective of  it,  tends  strongly  to  convergent  strabismus. 

Another  cause  of  internal  strabismus  is  paral3^sis  of  the 
sixth  nerve.     See  page  310. 

Divergent  Strabismus  is  generally' associated,  l,with 
mj-opia.  According  to  Donders,  about  two-thirds  of  the 
cases  are  due  to  this  cause ;  and  if  with  the  myopia  there 
is  a  large  posterior  staphyloma,  the  tendency  to  divergent 
strabismus  is  increased.  In  m3opia  there  is  frequeutl}' 
an  insufliciency  of  power  in  the  internal  recti,  and  a  pre- 
dominance being  thus  given  to  the  external  muscles,  di- 
vergent squint  is  produced.  This  insufficiency  may  be 
partly  caused  by  the  peculiar  lengthened  shape  of  a  highly 
myopic  eye,  which  not  only  mechanically  impedes  con- 
vergence beyond  a  certain  point,  but  also  diminishes  the 


288  STRABISMUS. 

fulcrum  upon  which  the  internal  recti  act.  If  a  well- 
marked  hj'permetropic  eye  be  contrasted  with  a  highly 
myopic  one,  this  will  at  once  be  evident.  As  the  internal 
recti  are  inserted  in  front  of  the  horizontal  equator  of  the 
eye^  the  abrupt  curve  of  the  almost  globular  hyperme- 
tropic e3'e,  round  which  the  muscles  curve  to  their  inser- 
tion, gives  to  them  an  excess  of  power  and  an  nndue 
facility  of  action,  which  favor  convergent  strabismus  ; 
whilst  in  the  highly  mjopic  eye  the  conditions  are  re- 
versed, the  globe  is  lengthened,  the  curve  of  its  equator 
is  diminished,  and  from  its  elongated  shape  its  facility 
of  movement  is  reduced.  Under  these  circumstances  the 
tendency-  in  mj^opia  is  for  the  internal  recti  to  lose  power, 
and  for  the  eye  to  diverge. 

Another  explanation  of  the  predominance  which  the 
external  recti  so  often  acquire  over  their  antagonists  in 
myopia,  is  to  be  found  in  the  great  refractive  power  of 
the  mj'opic  eye,  which  diminishes  the  necessity  for  ex- 
treme convergence  in  looking  at  near  objects,  and  favors 
divergence  in  striving  to  look  at  those  at  a  distance. 

2.  Divergent  strabismus  may  be  caused  by  a  diflference 
in  the  refractive  powers  of  the  two  eyes  when  both  are 
mj'opic.  For  all  close  work  the  better  eye  is  used,  and 
the  defective  eye,  failing  to  receive  an  impression  of  the 
object  sufficiently  strong  to  stimulate  it  to  convergence, 
rolls  outwards. 

3.  Defect  of  sight,  amounting  to  or  approximating 
blindness,  will  produce  divergent  strabismus. 

4.  Divergent  strabismus  may  follow  an  improper  or 
ill-advised  operation  for  convergent  strabismus. 

5.  Divergent  strabismus  maybe  produced  b}' paralysis 
of  the  third  nerve.     See  page  307. 

Treatment  of  Strabismus. — Inquire  carefully  into  the 
patient's  history,  and  endeavor  to  ascertain  the  duration 


TREATMENT.  289 

and  cause  of  the  squint.  Test  the  vision  of  both  e^'cs, 
note  their  range  of  action,  find  out  whether  the  strabismus 
is  periodic  or  persistent,  and  measure  the  extent  of  the  de- 
viation. If  there  is  a  faulty  state  of  the  refractive  powers 
of  the  eye,  tr}'^  to  neutralize  the  defect  with  proper  glasses. 

When  periodic  squint  is  suspected  to  arise  from  asca- 
rides,  dentition,  or  gastric  derangement,  the  first  treat- 
ment must  be  the  removal  of  the  source  of  irritation,  and 
when  this  is  accomplished,  the  e3'es  may  possibly  resume 
their  normal  position.  If,  however,  the  periodic  squint 
is  due  to  some  anomaly  in  the  refraction  of  the  eye,  an 
attempt  should  be  made  to  rectify  the  defect  by  the  use 
of  properly  fitted  glasses,  and  if  the  trial  is  made  suffl- 
cientl}^  early  there  is  a  fair  chance  of  success.  In  all  cases 
of  strabismus  which  are  dependent  on  a  faulty  state  of 
the  refractive  powers  of  the  ej^e,  as  in  hypermetropia  or 
myopia,  the  eyes  should  be  provided  with  proper  glasses, 
which  should  be  worn  even  if  an  operation  be  afterwards 
performed. 

Having  decided  on  an  operation,  it  at  once  becomes  a 
question  whether  it  will  be  necessary  to  divide  the  ten- 
dons of  the  corresponding  muscles  in  both  eyes,  or 
whether  a  tenotomy  in  one  eye  will  suffice.  Generally, 
it  is  better  to  operate  on  both  eyes,  and  to  divide  each 
tendon  as  close  to  the  globe  and  with  as  little  disturb- 
ance of  the  adjacent  tissues  as  possible.  In  this  way  the 
eflfect  to  be  obtained  is  apportioned  between  the  two  eyes, 
and  the  result,  I  think,  is  better  than  when  by  a  more  free 
division  of  the  subconjunctival  fascia  and  a  separation  of 
it  from  the  neighboring  parts,  the  operation  is  confined 
to  the  one  eye.  In  many  cases,  however,  it  is  prudent  to 
operate  first  on  the  one  e^'e  only,  and  then  to  wait  to  as- 
certain the  exact  effect  it  has  produced  before  proceeding 
to  divide  the  tendon  in  the  other  eye.  This  rule  should 
be  observed  in  the  treatment  of  strabismus  due  to  a  great 

25 


290 


STRABISMUS. 


defect  of  sight  in  one  e3'e,  and  especiall^^  if  tliere  is  a 
marked  limitation  of  movement  in  tlie  squinting  eye ;  it 
should  also  be  followed  in  slight  cases  of  alternating  stra- 
bismus. 

The  operation  for  strabismus  which  I  prefer  is  the  one 
most  frequently  adopted  at  the  Moorfields  Hospital.  It 
is  strictly  a  subconjunctival  operation,  in  the  sense  that 
the  division  of  the  tendon  is  accomplished  beneath  that 
membrane,  the  opening  in  it  for  the  necessary  introduc- 
tion of  the  instruments  being  opposite  the  inferior  edge 
of  the  tendinous  insertion  of  the  muscle. 


Fig.  29. 


The  Moorfields  Operation  for  Strabismus. — The 
lids  are  to  be  separated  by  a  stop-speculum.  The  surgeon 
with  a  pair  of  finely-toothed  forceps  takes  hold  of  the  con- 
junctiva, and  often  at  the  same  time  of  the 
deep  fascia  over  the  lower  edge  of  the  in- 
sertion of  the  rectus  tendon,  and  with  a  pair 
of  blunt-pointed  scissors  makes  a  small  open- 
ing through  both  these  structures.  If  the 
fascia  has  escaped  the  snip  of  the  scissors,  it 
must  be  seized  with  the  forceps  and  divided. 
The  blunt  hook  (Fig.  29)  is  now  passed 
through  the  apertures  in  the  conjunctiva  and 
deep  fascia,  and  behind  the  tendon,  which  it 
renders  tense  by  being  made  to  draw  it  for- 
wards and  towards  the  cornea.  The  points  of 
the  scissors  are  next  to  be  introduced,  and 
slightl3^  separating  them,  one  blade  is  passed 
along  the  hook  behind  the  tendon  and  the 
otlier  in  front  of  it,  when  by  a  succession  of 
small  snips  the  tendon  is  divided  subconjunc- 
tivall}'  on  the  ocular  side  of  the  hook. 

The  operation  is  now  conqjleted;  but  be- 
fore withdrawing  the  speculum,  Mr.  Uowman 


TREATMENT.  291 

usually  makes  a  small  counter-puncture  in  the  conjunc- 
tiva, by  bulging  it  on  the  end  of  the  hook  in  the  situation 
of  the  upper  border  of  the  tendon  after  its  division,  and 
by  then  snipping  it  with  the  scissors;  the  object  being  to 
allow  any  of  the  effused  blood  immediately  to  escape,  in- 
stead of  diffusing  itself  over  the  sclerotic. 

This  operation  is  equally  applicable  to  the  division  of 
either  the  internal  or  external  rectus  muscle.  It  must, 
however,  be  remembered  that  the  tendon  of  the  external 
rectus  is  inserted  into  the  globe  in  a  line  much  farther 
back  than  that  of  the  internal  muscle. 

Graefe's  Operation  for    Strabismus. — The   eyelids 
having  been  separated  by  a  speculum,  the  assistant  with 
a  pair  of  forceps  draws  the  eye  outwards   if 
the  internal  rectus  is  to  be  divided,  and  in-      Fio.  30. 
wards  if  the  operation  is  to  be  on  the  external      ^"^N^ 
rectus.     The  operator  then  with  a   pair  of 
finely-toothed  forceps  seizes  hold  of  a  fold  of 
the  conjunctiva  and  subjacent  tissue  close  to 
the  cornea,  and  at  a  point  a  little  below  the 
centre  of  the  insertion  of  the  muscle.    This  he 
cuts  through  with  a  pair  of  scissors,  sjlightly 
curved  on  the  flat,  and  then  burrowing  with 
their  points  a  little  distance  above  and  below 
the  opening  he  has  made,  he  freely  detaches 
with  a  few  snips  the  subconjunctival  tissue 
from  the  muscle.     The  squint  hook  (Fig.  30) 
is  now  passed  beneath  the  lower  border  of  the 
tendon,   which   is   to   be  divided   with   the 
scissors  as  close  as  possible  to  its  insertion 
into  the  globe.     After  the  tendon  has  been 
cut  through,  the  divided  conjunctiva  should  be  raised  with 
one  hook,  whilst  the  operator  with  another  hook  explores 
the  wound  both  upwards  and  downwards  to  see  if  any 


292  STRABISMUS. 

l^art  of  the  tendon  or  of  its  lateral  expansion  has  escaped 
division.  If  the  whole  tendon  has  been  cut  through,  the 
exploring  hook  will  glide  readily  up  to  the  margin  of  the 
cornea ;  but  if  its  progress  should  be  checked  by  catching 
behind  some  undivided  part  of  the  tendon,  the  scissors 
must  be  again  used  to  sever  that  which  still  remains  uncut. 

Liebreich's  Operation  for  Strabismus. — The  follow- 
ing is  Dr.  Liebreich's  account  of  his  "  modification  of  the 
operation  for  strabismus,"  which  w^as  first  published  in 
the  "British  Medical  Journal,"  December  15,  1866:  "If 
the  internal  rectus  is  to  be  divided,  I  raise  with  a  pair  of 
forceps  a  fold  of  conjunctiva  at  the  lower  edge  of  the  in- 
sertion of  the  muscle ;  and,  incising  this  with  scissors, 
enter  the  points  of  the  latter  at  the  opening  between  the 
conjunctiva  and  the  capsule  of  Tenon ;  then  carefully  sep- 
arate these  two  tissues  from  each  other  as  far  as  the  sem- 
ilunar fold,  also  separating  the  latter,  as  well  as  the  car- 
uncle from  the  parts  lying  behind.  When  the  portion  of 
the  capsule  which  is  of  such  importance  in  the  tenotomy 
has  been  completely  sei^arated  from  the  conjunctiva,  I 
divide  the  insertion  of  the  tendon  from  the  sclerotic  in  the 
usual  manner,  and  extend  the  vertical  cut,  which  is  made 
simultaneously  with  the  tenotomy,  upwards  and  down- 
wards— the  more  so  if  a  very  considerable  effect  is  desired. 
The  w^ound  in  the  conjunctiva  is  then  closed  with  a  suture." 

"  The  same  mode  of  operating  is  pursued  in  dividing 
the  external  rectus,  and  the  separation  of  the  conjunctiva 
is  to  be  continued  as  far  as  that  portion  of  the  external 
angle  which  is  drawn  sharpl^^  back  when  the  eye  is  turned 
outwards." 

The  advantages  which  he  claims  for  his  operation  are: 

"1.  It  affords  the  operator  a  greater  scope  in  appor- 
tioning and  dividing  the  effect  of  the  operation  between 
the  two  eyes. 


TKEATMENT.  293 

"  2.  The  sinking  back  of  the  caruncle  is  avoided,  as 
well  as  every  trace  of  a  cicatrix,  which  not  uufrequently 
occurs  in  the  common  tenotomy. 

"  3.  There  is  no  need  for  more  than  two  operations  on 
the  same  individual,  and,  therefore,  of  more  than  one  on 
the  same  eye." 

Treatment  of  Strabismus  after  the  Operation. — 
As  a  rule,  no  local  application  is  required  for  the  eyes, 
beyond  frequently  washing  them  with  a  little  tepid  water 
to  clear  them  from  the  slight  conjunctival  discharge  which 
usually  follows  for  a  few  days  after  the  operation.  If  the 
e3''es  are  hot  or  painful,  a  fold  of  linen  wet  with  cold  water 
may  be  laid  over  the  closed  lids,  but  the  eyes  should  not 
be  tied  up  with  a  bandage,  as  it  is  apt  to  increase  the 
sense  of  heat  and  to  add  to  the  discomfort  of  the  patient. 
AVhen  the  tendon  of  one  eye  only  has  been  divided,  the 
eye  which  has  not  been  operated  on  should  be  covered 
Avith  a  single  turn  of  a  bandage  immediately  after  the 
operation,  so  as  to  compel  the  patient  to  use  the  scpiint- 
ing  eye,  and  thus  to  keep  it  in  a  central  position  until 
the  divided  tendon  has  acquired  its  new  insertion.  If 
there  is  much  ecchymosis  on  the  second  or  third  day  after 
the  operation,  the  eye  may  be  frequentl}^  washed  with  a 
little  weak  lead  lotion  (F.  42) ;  or,  if  there  should  be  a 
muco-purulent  discharge,  a  mild  astringent  lotion  (F.  39, 
40)  may  be  used  three  or  four  times  daily. 

Divergent  Strabismus  following  the  Division  of 

ONE  OR  BOTH  THE  INTERNAL  ReCTI  MuSCLES This  re- 
sult may  occur  from  the  division  of  both  internal  recti 
when  one  only  was  required  ;  or  it  may  follow  a  too  free 
division  of  the  subconjunctival  fascia ;  or  it  may  arise 
from  the  tendon  having  been  divided  at  too  great  a  dis- 
tance from  its  insertion  into  the  globe.     In  both  of  the 

25* 


294  STRABISMUS. 

last-mentioned  cases  the  muscle  recedes  too  much,  and 
takes  its  new  insertion  into  the  globe  so  far  back  that  it 
loses  more  of  its  poAver  than  is  necessar}'  for  the  correc- 
tion of  the  squint,  and,  consequently',  gives  to  the  exter- 
nal rectus  a  predominance  which  makes  the  eye  diverge. 
With  this  form  of  strabismus,  there  is  nearly  alwa^'s  as- 
sociated a  sinking  back  of  the  caruncle,  a  defect  which 
gives  an  unsightly  prominence  to  the  globe,  and  favors 
its  ev'ersion. 

Treatment. — If  divergence  follow  shortly  after  an  opera- 
tion for  a  convergent  strabismus,  in  which  the  internal 
recti  of  both  eyes  have  been  divided,  a  subconjunctival 
tenotomy  should  be  performed  on  both  the  external  recti, 
and  this  should  be  done  even  though  the  divergence  be 
slight,  as,  when  once  established,  the  eversion  will  steadily 
increase.  If,  however,  the  divergence  is  the  result  of  a 
too  free  division  of  the  internal  rectus  and  adjacent  tis- 
sues of  one  exje^  then  the  external  rectus  of  that  e^^e  only 
should  be  divided ;  and,  if  this  fails  to  correct  the  out- 
ward deviation,  the  tendon  of  the  internal  rectus  must 
be  brought  forward  by  an  operation  at  a  subsequent  pe- 
riod. Whenever  the  divergence  is  considerable,  and  the 
power  of  inversion  limited,  the  simple  subconjunctival 
division  of  the  external  recti  will  not  restore  the  eyes 
to  position,  but  the  following  operation,  which  was  sug- 
gested by  Mr.  Critchett,  must  be  performed  on  one  or 
both  e3'es,  according  to  the  circumstances  of  the  case. 

Operation  for  bringing  forward  the  Insertion  of 
THE  Internal  Rectus  Muscle.  —  The  lids  are  to  be 
separated  with  the  ordinary  spring  speculum,  and  the 
ej'e  is  to  be  drawn  inwards  whilst  the  operator  divides 
subconjunctival!}^  the  tendon  of  the  external  rectus. 
The  division  of  this  muscle,  at  the  commencement  of  the 
operation,  facilitates  the  further  proceedings.     A  vertical 


TREATMENT.  295 

cut  is  now  to  be  made  with  a  pair  of  scissors  through  the 
conjunctiva  and  deep  fascia  in  a  line  corresponding  with 
the  inner  margin  of  the  cornea,  but,  at  1^'"  or  2'"  from 
it,  and  then,  with  a  few  successive  snips,  the  conjunctiva 
and  subjacent  fascia  are  to  be  separated  from  the  inner  side 
of  the  globe  as  far  back  as  the  inner  caruncle.  In  doing 
this,  care  must  be  taken  to  divide  the  new  insertion  of 
the  internal  rectus,  so  that,  in  drawing  forwards  the  tis- 
sues which  have  been  thus  detached  from  the  globe,  the 
tendon  of  the  internal  rectus  will  be  raised  with  them.  A 
vertical  slip  of  the  conjunctiva  and  fascia  is  now  to  be 
cut  away,  and  the  edges  of  the  wound  are  then  to  be 
brought  accurately  together  with  sutures.  To  accom- 
plish this,  three  stitches  of  the  finest  silk  will  be  required ; 
the  centre  one  should  be  inserted  first ;  it  should  be  passed 
through  the  slip  of  conjunctiva  which  was  left  at  the  edge 
of  the  cornea,  and  through  the  deep  fascia  and  conjunc- 
tiva close  to  the  caruncle,  so  that,  when  fastened,  the  eye 
will  be  drawn  inwards,  and  the  caruncle  raised.  The  up- 
per and  lower  stitches  are  next  to  be  introduced,  and  the 
assistant  then  gently  inverts  the  e3^e  whilst  the  threads 
are  being  tied.  When  all  is  completed,  the  e^^e  should 
have  a  decided  inteinial  strabismus,  as  the  after  result  is 
always  considerably  less  than  that  which  is  obtained  at 
the  time  of  the  operation.  For  the  first  twentj^-four  hours 
after  the  operation,  a  fold  of  linen,  wet  with  cold  water, 
should  be  applied  over  the  closed  lids,  and  it  may  be  con- 
tinued as  long  as  the  e^^e  feels  hot  or  painful.  The 
stitches  should  be  removed  about  the  fourth  or  sixth  day 
after  the  operation. 


296  TARALYSIS    OF    CILIARY    MUSCLE. 


PARALYSIS    AND    SPASM    OF    THE    CILIARY    MUSCLE. 

Paralysis  of  the  Ciliary  Mlfscle.  —  This  affection 
is  usually  occasioued  by  some  depressing  illness,  and 
especially  fever  and  diphtheria.  It  is  generally  first  no- 
ticed during  the  convalescence,  when  it  is  discovered 
accidentally  by  the  patient.  The  paralysis  varies  greatly 
in  its  extent,  but  it  is  seldom  complete.  It  mostly  attacks 
children,  but  I  have  met  with  it  once  in  an  adult,  an  ac- 
count of  which  case  I  published  in  the  "  Lancet."* 

Paralysis  of  the  ciliary  muscle  may  be  induced  arti- 
ficially by  frequent  instillations  into  the  eye  of  a  strong 
solution  of  atropine  (F.  14). 

Symjjfoms A  loss  of  the  accommodative  power  of  the 

eye  in  proportion  to  the  degree  of  the  paralysis;  things 
far  off  are  seen  clearly,  but  those  which  are  near  are  either 
very  misty  or  quite  undistinguishable.  The  far  |X)int  of 
vision  is  unaltered,  but  the  near  point  is  carried  to  a 
distance  from  the  eye.  With  a  convex  glass  near  objects 
are  again  rendered  distinct ;  the  strength  of  the  lens  which 
an  emmetropic  eye  affected  with  paresis  requires  for  near 
vision,  affords  a  fair  estimate  of  the  loss  of  power  it  has 
sustained.  In  a  severe  case  the  patient  may  be  unable 
to  see  distinctly  No.  16  of  Jaeger,  and  yet  with  proper 
convex  glasses  read  with  facility  No.  1.  The  following 
account  of  a  child  who  was  under  my  care,  suffering  from 
paralysis  of  the  accommodation  of  the  eye,  is  a  good  ex- 
ample of  this  disease. f 

W.  11.,  set.  11,  a  pale,  delicate,  but  bright  and  intelligent 
lad,  was  brought  by  his  father  to  the  hospital  on  account 
of  what  appeared  a  sudden  great  impairment  of  vision  of 
both  e3^es.     His  history  was,  that  up  to  a  fortnight  pre- 

*  Lancet,  May  11,  1861.  f  Ibid.,  October  14,  18G2. 


SPASM    OF   CILIARY   MUSCLE.  297 

viously  he  had  always  had  good  sight,  and  could  read  and 
write  with  perfect  ease.  Six  weeks  before  coming  to  the 
hospital  he  had  a  low  fever,  from  which  he  made  a  fair 
recovery,  but  was  much  reduced  hj  it.  One  day,  shortly 
after  his  illness,  he  discovered,  on  attempting  to  read,  that 
he  was  unable  to  do  so,  but  that  he  could  distinguish  ob- 
jects at  a  distance.  Examined  with  Jaeger's  test-types, 
he  could  only  read  No.  XVI  at  fifteen  inches  from  his 
e3'es,  but  he  could  with  facility  tell  the  hour  of  the  hospital 
clock  at  twenty-six  feet.  With  a  convex  lens  of  24"  focus 
he  could  read  at  twelve  inches  No.  XII ;  with  a  lens  of 
18"  focus  No.  VIII;  with  one  of  12"  focus  No.  IV;  and 
with  a  9"  focus  lens  No.  I.  This  bo}^  was  treated  with 
purgatives,  iron,  good  diet,  and  perfect  rest  to  eyes,  and 
within  a  month  he  was  able  to  read  No.  I  perfectly  with 
either  eye,  and  could  see  as  well  as  ever  he  did. 

The  prognosis  is  favorable.  All  the  cases  I  have  seen 
have  ultimately  recovered. 

Ti^eatment.  —  Absolute  rest  to  the  eyes;  no  convex  r 
glasses  should  be  given  to  allow  the  patient  to  read.  For  i, 
children,  the  preparations  of  barlv  or  iron  (F.  110,  111,  \ 
116,  117)  should  be  prescribed,  with  change  of  air.  For  \ 
adults,  the  mist,  acidi  cum  cinchona  (F.  61),  or  the  mist.  I 
ferri  perchlor.,  either  with  or  without  small  doses  of  strych-  \ 
nia  (F.  69,  70). 

As  a  local  apj^lication^iho,  Gycs  ma3^be  frequently  bathed 
with  cold  water,  or  a  cold  douche  may  be  used  with  the 
lids  closed. 

Spasm  of  the  Ciliary  Muscle  is  a  rare  but  an  occa- 
sional complication  of  hypermetropia,  which  it  masks  by 
rendering  the  q\%  temporarily  myopic,  so  that  distant 
vision  is  improved  by  concave  glasses. ,  It  is  usually  in- 
duced from  overstraining  hypermetropic  eyes  in  repeated 
endeavors  to  read  or  do  close  work,  without  the  aid  of 


298  DIPLOPIA. 

proper  convex  glasses.  It  is  productive  of  ])ain  and  a 
feeling  of  tension  of  the  eyes  after  using  them  for  a  short 
time  at  near  objects,  as  in  reading,  writing,  &c.  This 
affection  may  be  diagnosed  by  the  ophthalmoscope,  when, 
in  spite  of  the  apparent  myopia,  the  eye  exhibits  a  hyper- 
metropic refraction.  It  may  also  be  detected  b}'  placing 
the  eye  completely  under  the  influence  of  atropine,  so  as 
to  paral^^ze  the  ciliary  muscle,  and  then  testing  the  re- 
fraction with  convex  glasses.  See  article  Hypermetropia, 
page  2t0. 

Spasm  of  the  ciliary  muscle  may  be  caused  artificially 
by  applying  the  Calabar  bean  to  the  eye.  See  article 
Calabar  Bean,  page  110. 

Treatment. — Order  the  patient  to  abstain  from  all  work, 
and  use  the  guttoe  atropioe  (F.  14)  twice  daily  for  several 
days.  The  eye  may  be  then  tried  with  convex  glasses,  and 
having  ascertained  the  degree  of  hjq^ermetropia,  suitable 
spectacles  may  be  ordered,  but  they  should  not  be  worn 
until  the  eyes  have  had  at  least  live  or  six  weeks'  complete 
rest. 

DIPLOPIA. 

Diplopia,  or  double  vision,  is  produced  b}'  any  cause 
which  prevents  the  optic  axes  from  being  directed  jointly 
on  the  same  point,  so  that  the  impressions  cannot  fall  on 
corresponding  parts  of  the  two  retina.  Two  objects  are 
seen,  a  true  and  a  false  one,  the  latter  varying  in  position 
with  respect  to  the  former  according  to  the  strabismus 
which  is  given  by  the  excess  of  power  in  one  or  more  of 
the  ocular  muscles.  The  existence  of  diplopia  of  course 
implies  that  the  patient  has  binocular  vision. 

Thei'e  are  two  forms  of  diplopia,  homonymous  and 
crossed. 

Homonyynous  or  direct  diplopia  is  met  with  in  conver- 
gent strabismus,  when  the  rays  from  the  object  fall  in  one 


ACTION    OF   PRISMS.  299 

eye  on  the  retina  internal  to  the  j-ellow  spot.  The  false 
impression  is  projected  outwards,  and,  if  emanating  from 
the  right  eye,  is  seen  on  the  right  or  outer  side  of  the  true 
object. 

Grossed  dijplopia  occurs  in  external  or  divergent  stra- 
bismus, when  the  rays  from  the  object  are  brought  to  a 
focus  in  one  eye  on  the  retina  external  to  the  yellow  spot. 
The  false  image  is  projected  inwards  across  the  nose : 
thus,  if  it  proceed  from  the  right  eye  it  is  seen  on  the  left 
of  the  true  object. 

THE    ACTION   AND    USES    OF    PRISMS. 

The  rays  of  light  as  they  pass  through  a  prism  are  de- 
flected towards  its  base ;  hence  it  is,  that  if  a  prism  is 
placed  in  front  of  the  eye  with  its  base  towards  the  nose, 
the  rays  being  bent  inwards  will  be  brought  to  a  focus  at 
a  point  internal  to  the  yellow  spot.  The  patient  would 
now  have  diplopia ;  but  in  order  to  unite  the  two  images, 
and  bring  them  on  corresponding  parts  of  the  two  retinie, 
he  squints  involuntarily  outwards,  and  if  the  prism  is  a 
weak  one,  he  succeeds  in  overcoming  the  displacement. 
The  strabismus  which  is  thus  produced  is  called  a  correc- 
tive squint.  But  if  the  prism  is  strong,  the  patient  is 
unable  in  this  manner  to  correct  the  displaced  image,  and 
he  has  diplopia. 

Prisms  will  be  found  useful — 

1.  To  ascertain  the  presence  of  binocular  vision. 

2.  To  test  the  strength  of  the  muscles  of  the  eye. 

3.  To  wear  as  spectacles  to  correct  diplopia. 

1.  To  ascertain  the  j)7^ese^ice  of  Binocular  Vision,  that 
is,  to  detei'mine  whether  the  patient  uses  both  eyes  in 
looking  at  an  object.  Place  a  prism  of  about  12°  in  front 
of  one  eye  with  its  base  outwards,  if  there  is  at  once  a 
corrective  inwards  squint,  we  may  be  satisfied  that  the 


300  ACTION   OF   PRISMS. 

patient  eiijo^ys  binocular  vision.  If,  however,  there  is  no 
movement  of  the  eye,  and  no  diplopia,  it  shows  that  the 
patient  does  not  nse  that  eye,  but  that  he  is  looking  with 
the  other,  and  has  not  therefore  binocular  vision.  If  now 
the  prism  is  placed  before  the  eye  which  he  does  use,  it 
will  at  once  move  slightly  inwards,  but  it  will  not  be  a 
corrective  squint,  for  the  other  eye  will  at  the  same  time 
go  an  equal  distance  outwards,  showing  that  it  is  only  an 
associated  movement.  This  mode  of  examining  the  eye 
is  often  of  great  service  in  detecting  impostors,  who,  for 
some  reason  known  only  to  themselves,  are  feigning  the 
loss  of  sight  of  one  e^'e — in  many  cases  for  the  sake  of 
compensation  after  injur3^ 

2.  To  test  with  Prisms  the  relative  Strength  of  the 
Iluscles  of  the  Eye. — A  normal  eye  can  overcome  a  prism 
of  from  16°  to  24°  with  its  base  turned  outwards  ;  but 
with  its  base  inwards,  only  one  of  from  6°  to  8° — that  is 
to  say,  by  a  corrective  squint  it  can  so  readjust  the  dis- 
placed image  on  the^ retina,  that  there  is  no  diplopia,  but 
binocular  vision.  In  order  to  determine  the  degree  of  in- 
sufficiency of  power  of  the  internal  recti,  try  what  is  the 
strongest  prism  wath  its  base  turned  outwards  each  eye  is 
able  to  overcome.  A  lighted  candle  should  be  placed 
seven  or  eight  feet  in  front  of  the  patient,  at  which  he  is 
to  be  directed  to  look.  If  he  is  short-sighted,  sufficiently 
powerful  concave  glasses  should  be  given  to  him  to  enable 
him  to  see  the  light  distinctly.  Prisms  of  increasing 
strengths  should  now  be  held  in  succession  with  their 
bases  outwards  before  one  e^e,  until  it  is  decided  which 
is  the  strongest  he  can  see  through  without  diplopia.  The 
power  of  the  prism  which  he  can  thus  overcome,  compai-ed 
with  that  which  a  normal  eye  can  master,  will  indicate  the 
degree  of  insufficiency  of  the  internal  rectus  of  that  eye. 
The  other  eye  must  then  be  tested  in  a  similar  manner. 
It  will  be  thus  sometimes  found  that  the  strength  of  the 


ACTION    OF    PRISMS.  301 

internal  mnscles  has  been  so  reduced,  that  instead  of 
being  able  to  correct  the  displaced  image  produced  by  a 
prism  of  16°  to  24°  as  in  the  normal  eye,  they  can  only 
overcome  one  of  from  4°  to  6°.  Conversely,  the  strength 
of  the  external  recti  may  be  ascertained  by  testing  the 
eyes  with  prisms  with  their  bases  directed  inwards.  An- 
other method  of  measuring  the  strength  of  the  muscles  of 
the  eye  is  as  follows  : 

A  normal  eye  can  onl}'  overcome  a  prism  of  from  1°  to 
2°,  if  the  base  be  turned  either  ujd wards  or  downwards. 
Place,  therefore,  in  front  of  the  e3'e  a  prism  of  a  higher 
degree,  and  diplopia  will  be  produced ;  the  false  object 
will  be  projected  either  directly  above  or  below  the  true 
one.  If  the  prism  is  held  with  its  base  upwards,  the  false 
image  will  appear  below ;  and  if  the  base  is  placed  down- 
wards, the  wrong  impression  will  show  itself  above  the 
true  one,  but  they  will  both  appear  in  the  same  line. 
This,  however,  is  on  the  supposition  that  the  external 
and  internal  recti  of  the  two  ejes  exactly  balance  each 
other.  If  they  do  not^  the  false  object  will  not  only  ap- 
pear either  above  or  below  the  true  one,  but  it  will  be 
cast  either  to  its  outer  or  inner  side,  according  to  the 
predominance  of  power  of  the  external  or  internal  recti, 
and  the  diplopia  will  be  then  either  crossed  or  homony- 
mous. A  slip  of  red  glass  placed  in  front  of  one  of  the 
ej'es  will  at  once  determine  the  form  of  the  diplopia,  by 
giving  a  colored  tint  to  one  of  the  objects,  and  thus  in- 
dicating which  of  the  two  is  the  false  impression.  The 
extent  of  the  insufficiency  ma}^  then  be  ascertained  by 
trying  what  prism,  placed  in  front  of  the  one  with  its  base 
upwards,  will  restore  the  false  and  true  images  to  a  di- 
rect line  one  above  the  other.  Of  course,  if  the  diplopia 
is  found  crossed,  the  prisms  must  be  tried  before  the  e^-e 
with  their  bases  turned  inwards ;  and,  if  homonymous, 
with  their  bases  placed  outwards.     If  the  diplopia  is 

26 


302  PARALYSIS    OF    MUSCLES    OF    THE    EYE. 

crossed,  it  indicates  an  excess  of  j>owcr  in  the  external 
recti,  and  consequently  an  insufficiency  of  the  internal 
muscles ;  and  the  reverse  if  the  diplopia  is  homonymous. 
To  tvear  as  Spectacles  to  Correct  Dij)lojna — In  cases 
of  paralytic  strabismus,  prisms  are  often  of  great  service, 
and  especially  during  the  progress  of  recovery  from  palsy 
of  the  sixth,  or  partial  paralysis  of  the  third  nerve,  in 
which  the  internal  rectus  is  the  only  muscle,  or  the  one 
principally  affected,  and  where  from  special  reasons  the 
patient  objects  to  keep  the  eye  covered  to  avoid  the 
diplopia.  The  spectacles  should  be  furnished  with  a 
piece  of  plane  plate  glass  for  the  sound  eye,  and  with 
a  rightly  adjusted  prism  for  the  paralytic  one.  Whilst 
using  the  prism,  the  patient  should  be  kept  nnder  obser- 
vation, as,  if  the  case  is  progressing  to  a  favorable  termi- 
nation, the  prism  will  require  to  be  frequently  changed 
for  another  of  a  lower  degree,  as  the  paralj'zed  muscle 
gradually  regains  power,  until,  at  last,  its  use  ma}^  be 
abandoned. 

PARALYTIC    AFFECTIONS   OF    THE    MUSCLES    OF    THE    EYE. 

The  subject  of  paralysis  of  the  separate  nerves  which 
suppl}^  the  muscles  of  the  ej^e,  is  involved  in  considerable 
obscurit}',  as  although  in  man}^  cases  the  diagnosis  of  tlie 
paralysis  is  clear,  3'et  in  a  vast  number  it  is  difficult  to 
assign  awy  satisfactory  explanation  for  the  sudden  or 
gradual  loss  of  power  in  the  structures  supplied  by  one 
particular  nerve.  Either  the  third,  fourth,  or  sixth  nerve 
may  become  paralyzed,  without  there  being  evidence  of 
disease  in  any  other  portion  of  the  nervous  system.  The 
loss  of  power  may  be  sudden,  or  it  may  be  gradual, 
the  paralytic  symptoms  increasing  daily  until  they  have 
reached  a  certain  point,  at  which,  for  a  time,  they  usually 
remain  stationary.     After  a  variable  interval,  the  nerve, 


CAUSES    OF    PARALYSIS.  303 

as  a  rule,  begins  to  recover  its  tone,  and  the  parts  sup- 
plied by  it  ultimately  resume  their  normal  action. 

The  immediate  result  of  paralysis  of  one  of  these 
nerves  is  a  strabismus,  caused  by  a  loss  of  the  balance 
between  the  muscles  of  the  affected  eye.  This  is  termed 
a  jyaralytic  sti^abismus,  to  distinguish  it  from  those  forms 
of  squint  which  are  dne  to  some  anomal^^  in  the  refrac- 
tion of  the  eye.  The  paral3^tic  strabismus  has  this  char- 
acteristic, that  whereas,  in  the  concomitant  squint,  the 
primary  and  secondary  deviations  are  equal;  in  the  para- 
lytic, the  secondary  is  greater  than  the  primary.  This 
is  easily  seen  by  making  the  following  examination.  If 
the  sound  eye  be  covered  with  the  hand,  and  the  patient 
be  directed  to  look  at  a  given  point,  the  primary  devia- 
tion or  movement  of  the  paralyzed  eye  will  be  far  less 
than  the  associated  or  secondary  movement  of  the  sound 
one. 

Paralysis  of  one  or  more  of  the  ocular  nerves  may  be 
caused  by — 

a.  Intra-cranial  disease. 
/5.  Intra-orbital  disease. 

y.  Blood-poisoning,  such  as  syphilis,  rheumatism,  and 
gout. 

8.  Reflex  irritation. 

a.  From  Intra-cranial  Disease. — When  paralysis  of  the 
ocular  muscles  proceeds  from  disease  of  the  brain,  it  is 
seldom  confined  to  the  structures  supplied  b}^  one  par- 
ticular nerve  ;  or  if  during  the  early  s^^mptoms  only  one 
nerve  is  involved,  there  are  usually  other  indications  of 
cerebral  mischief.  The  patient  totters  or  trips  in  walk- 
ing, or  has  pain  or  giddiness  in  the  head,  or,  perhaps,  has 
some  loss  of  power  in  the  muscles  of  expi-ession,  or  a 
diminution  of  sensibility  in  the  skin  of  the  face. 

/?.  From  Intra-orbital  Disease. — Pressure  upon  any  of 


304  PARALYSIS    OF    MUSCLES    OF    THE    EYE. 

the  ocular  nerves  in  their  course  along  the  orLit  to  the 
eye  will  cause  a  partial  or  complete  paral3'sis  of  their 
functions.  This  may  be  induced  by  a  tumor  within  the 
orbit,  or  by  an  orbital  node,  or  by  some  inflammatory  or 
specific  exudation  either  around  the  nerve  or  within  its 
sheath. 

y.  From  BJood-jJoisom'ng. — To  either  sj^philis,  rheuma- 
tism, or  gout,  many  of  the  cases  of  paral^'sis  of  one  of  the 
motor  nerves  of  the  eye  are  to  be  attributed.  A  thick- 
ening of  the  fibrous  sheath  of  dura  mater,  through  which 
the  nerve  runs  in  its  passage  to  the  orbit,  or  some  inflam- 
matory exudation  peculiar  to  the  affection  from  which  the 
patient  suffers,  may  compress  the  nerve  and  paralyze  its 
functions.  We  have  illustrations  of  analogous  forms  of 
local  palsy  in  the  paralysis  of  the  muscles  of  the  face, 
from  palsy  of  the  portio  dura  of  the  seventh  nerve,  and 
in  facial  anaesthesia  from  palsy  of  the  fifth.  Both  of  these 
examples  may  undoubtedly  be  due  to  a  pressure  on  the 
nerves,  either  from  an  inflammator}^  thickening  of  neigh- 
boring structures,  or  from  some  morbid  deposit  depend- 
ent on  a  blood-poison. 

8.  From  Refiex  Irritation. — It  is  always  difficult  to  ob- 
tain direct  evidence  to  prove  that  the  functional  disturb- 
ance of  a  nerve  is  dependent  on  distant  irritation.  I 
think,  however,  that  there  can  be  no  doubt  but  that  many 
of  the  forms  of  local  paralysis  which  are  met  with  both  in 
the  child  and  the  adult  are  due  to  this  cause,  and  that 
frequentl}^  the  palsy  of  an  ocular  nerve  may  also  arise 
from  it.  The  most  striking  illustrations  of  this  class  of 
disease  are  to  be  found  in  the  cases  of  infantile  paralj'sis, 
where  a  single  muscle,  as  the  tibialis  anticus  or  the  long 
extensor  of  the  toes,  or  a  group  of  muscles,  as  the  flexors 
or  the  extensors  of  the  leg,  become  suddenly  deprived  of 
power.  Mr.  William  Adams,  in  speaking  of  intautile 
paralysis,  says :  "  It  is  frequently  neither  preceded  nor 


PARALYSIS    OF    THE    TIIIllD    NERVE.  305 

accompanied  by  any  cerebral  sjnnptoms,  and,  even  when 
such  symptoms  show  themselves,  they  are  generally  of  a 
transient  character."  And  further  on  he  remarks:  "This 
form  of  paralysis  generally  takes  place  during  the  period 
of  first  dentition,  and  would  seem  to  be  connected  with 
the  irritation  attending  this  process ;"  and,  "  that  a 
marked  characteristic  of  this  affection  is  a  tendency  to 
spontaneous  cure."* 

On  inquiring  into  the  history  of  many  of  the  cases  of 
pais}'  of  an  ocular  nerve,  no  s3^mptoms  of  S3'^philis,  rheu- 
matism, or  gout  are  to  be  detected,  and  there  are  no  evi- 
dences of  brain  disease  or  mischief  within  the  orbit.  A 
further  investigation,  however,  will  frequently  discover 
as  the  cause  of  the  palsy  some  eccentric  irritation  in  a 
disorder  of  the  liver,  stomach,  or  some  other  portion  of 
the  intestinal  canal. 

The  analogy  between  infantile  paralysis  and  some  of 
the  cases  of  palsy  of  the  ocular  muscles  at  once  becomes 
manifest.  In  both,  cerebral  symptoms  may  be  wanting, 
or  may  have  been  only  transient ;  in  both,  remote  irrita- 
tion may  be  the  exciting  cause  of  the  palsy.  In  children 
it  is  usually  dentition,  and  in  adults  a  derangement  of  the 
abdominal  viscera;  and,  lastly,  in  both  we  have  the  same 
tendencj'  to  spontaneous  cure.  The  nerve  which  is,  I  be- 
lieve, the  most  frequently  affected  from  reflex  irritation, 
is  the  sixth. 

Before  describing  the  symptoms  which  indicate  paral}^- 
sis  of  one  or  more  of  the  muscles  of  the  ej'e,  I  will  first 
briefly  refer  to  the  anatomy  and  function  of  each  of  the 
motor  ocular  nerves. 

The  Third  Nerve — mofot^  oculi — is  the  largest  of  the 
three  motor  nerves  which  supply  the  muscles  of  the  e3'e. 

*  Chib-Foot,  by  William  Adams,  pp.  61,  fl2. 
26* 


306  PARALYSIS    OF    MUSCLES    OF   THE    EYE. 

In  its  course  along  the  outer  wall  of  the  cavernous  sinus 
it  divides  into  two  branches,  superior  and  an  inferior^ 
which  enter  the  orbit  through  the  sphenoidal  fissure,  pass- 
ing between  the  two  heads  of  the  external  rectus. 

a.  The  superior  division  supplies. 
The  levator  palpebrse. 
The  superior  rectus. 

[i.  The  inferior  division  supplies. 
The  internal  rectus. 
The  inferior  rectus. 

The  inferior  oblique,  and  a  branch  to  the 
lenticular  ganglion  (its  short  root). 

In  addition  to  the  above-named,  the  third  nerve  through 
its  branch  to  the  lenticular  ganglion  supplies,  under  the 
name  of  the  ciliary  nerves,  the  muscular  structures  within 
the  ej'e,  the  ciliary  muscle,  and  sphincter  pupillse  of  the? 
iris. 

In  the  outer  wall  of  the  cavernous  sinus  the  third  nerve 
communicates  with  the  ophthalmic  division  of  the  fifth, 
and  with  the  cavernous  plexus  of  the  s^ympathetic. 

The  functions  of  the  third  nerve  are :  to  preside  over 
the  action  of  the  muscles  to  which  it  sends  branches,  and, 
under  the  influence  of  light  upon  the  retina,  to  effect  the 
contraction  of  the  pupil.  "  The  motor  action  of  the  third 
nerve  may,  therefore,  be  excited  through  the  optic  nerve. 
There  can  be  no  doubt,  indeed,  that  this  is  the  ordinary 
method  b}^  which  contraction  of  the  pupil  is  produced 
during  life ;  the  stimulus  of  light  falling  upon  the  retina 
excites  the  optic  nerve,  and  through  it  that  portion  of  the 
brain  in  which  the  third  nerve  is  implanted."* 

Paralysis  of  the  third  nerve  may  be  either  comj^Iete  or 
2:>a7^tial. 

*  Todd  and  Bowinau's  Physiological  Anatonij-,  1st  edit.,  vol. 
ii,  p.  103. 


PARALYSIS    OF    THE    THIRD    NERVE.  307 

When  the  paralysis  is  covijylefe,  there  is  an  al)sohite 
loss  of  i^ower  in  all  the  structures  of  the  eye  supplied  b^' 
the  third  nerve.  The  levator  palpebr^e  being  palal^zed, 
the  upper  lid  droops  over  the  'eye,  and  cannot  be  raised 
by  the  patient.  The  superior,  inferior,  and  internal  recti, 
and  the  inferior  oblique  muscles,  have  ceased  to  exercise 
any  control  over  the  movements  of  the  globe,  and  the  eye 
is  under  the  dominion  of  the  external  rectus  and  the  su- 
perior oblique,  which,  acting  together,  draw  the  globe 
outwards  and  slightly  downwards.  A  strong  divergent 
strabismus  is  thus  given  to  the  eye,  and  the  patient  has 
crossed  diplopia,  the  false  object  appearing  across  the 
nose  on  the  other  side  of  the  true  one.  See  Crossed 
Diplopia,  page  298.  But,  in  addition  to  this,  the  pupil 
is  widely  dilated,  and  from  paralysis  of  the  ciliary  muscle 
the  accommodation  is  destroyed.  From  the  complete  re- 
laxation of  so  many  of  the  ocular  muscles,  there  is  gener- 
ally a  slight  protrusion  of  the  globe.  If  the  patient  be 
directed  to  close  the  sound  eye,  he  will  generally  walk 
with  an  unsteady  gait,  and  miss  the  objects  he  endeavors 
to  seize.  Such  are  the  symptoms  of  a  complete  paral3'sis 
of  the  third  nerve ;  but  it  is  seldom,  except  in  cases  of 
cerebral  disease  or  of  tumors  in  the  orbit,  that  all  the 
branches  of  the  nerve  are  thus  affected. 

Partial  paralyKis  of  the  third  nerce  mny  exist  in  two 
forms. 

a.  There  may  be  a  diminution  rather  than  absolute  loss 
of  power  in  all  the  structures  which  the  nerve  supplies, 
and  the  patient  then  exhibits  the  sjiuptoms  already-  de- 
scribed, but  modified  in  degree.  The  ptosis  is  only  par- 
tial ;  the  pupil  is  dilated  but  not  to  its  utmost,  and  the 
accommodative  power  of  the  eye  is  diminished ;  there  is 
a  divergent  strabismus  with  crossed  diplopia,  but  it  is 
not  extreme,  and,  with  an  extraordinary-  effort,  the  pa- 


308  PARALYSIS    OF   MUSCLES    OF   THE    EYE. 

tient  can  draw  the  eye  either  slightly- inwards,  upwards, 
or  downwards. 

/5.  In  many  eases,  however,  of  partial  paralysis  of  the 
third  nerve,  some  of  its  filS,ments  only  are  affected.  The 
loss  of  power  may  be  confined  to  one  or  more  of  the  recti 
muscles,  an}'  one  of  whicli  may  be  separately  paralj'zed ; 
but  the  pals}^  is  seldom,  if  ever,  limited  to  the  inferior 
oblique.  The  muscle  which  is  the  most  frequently  in- 
volved, is  the  internal  rectus ;  it  is  rare  for  the  superior 
or  inferior  rectus  to  be  paral^'zed  whilst  the  intenial 
muscle  remains  intact.  The  pupil  is  generall}'  more  or 
less  dilated,  but  I  have  seen  it  in  exceptional  cases  of  its 
normal  size ;  the  levator  palpebrae  frequently  retains  its 
influence  over  the  upper  lid,  even  when  one  or  more  of 
the  muscles  of  the  eye  are  paral^'zed.  There  is  always 
some  diplopia,  the  false  object  var^'ing  in  position  with 
respect  to  the  true  one,  in  accordance  with  the  muscle  or 
muscles  which  have  lost  their  power,  thus  : 

In  paralysis  of  the  internal  rectus^  there  is  a  divergent 
strabismus,  but  the  eye  can  be  turned  upwards  or  down- 
wards. The  diplopia  is  crossed,  and  the  false  object  is 
on  a  level  with  the  true  one. 

In  paralysis  of  the  superior  rectus^  the  e3'e  is  displaced 
downwards  and  outwards  b}'  the  combined  action  of  the 
inferior  and  external  recti  and  superior  oblique  muscles, 
whenever  an  attempt  is  made  to  look  up.  The  diplopia 
is  crossed,  and  the  false  object  is  above  the  level  of  the 
ti'ue  one. 

In  paralysis  of  the  inferior  rectus^  the  eye  deviates 
upwards  and  outwards  by  the  combined  action  of  the 
superior  and  external  recti,  and  the  inferior  oblique  mus- 
cles, when  an  effort  is  made  to  look  down.  The  diplopia 
is  crossed,  and  the  false  object  is  projected  below  the 
level  of  the  true  one. 


PARALYSIS    OF    THE    FOURTH    AND    SIXTH    NERVE.       309 

The  Fourth  Xerve — the  trochlear — the  smallest  of  the 
cerebral  Jierves,  passes  along  the  outer  wall  of  the  cavern- 
ous siuus,  and  enters  the  orbit  by  the  sphenoidal  fissure. 
It  then  mounts  above  the  other  nerves,  and  running  close 
to  the  periosteum  of  the  roof  of  the  orbit,  it  applies  itself 
to  the  orbital  surface  of  the  superior  oblique  muscle.  As 
it  traverses  the  Avail  of  the  cavernous  sinus,  it  communi- 
cates with  the  s^-mpathetic  through  filaments  from  the 
carotid  plexus,  and  as  it  enters  the  orbit,  it  occasionall}'^ 
gives  a  branch  to  the  lachrymal  nerve.  The  function  of 
the  fourth  nerve  is  entirel}'  motor. 

In  paralijsis  of  the  fourth  nerve^  the  earh'  symptoms 
are  often  obscure  and  easily  overlooked ;  but  when  the 
palsy  is  complete,  they  are  usually  sufficiently  marked  to 
be  diagnosed  by  a  careful  examination  of  the  eye.  It 
should  be  remembered  that  the  function  of  the  superior 
oblique,  in  health,  is  to  roll  the  eye  downwards  and  out- 
wards, and  that  therefore  no  defect  of  sight,  arising  from 
a  want  of  power  in  this  muscle,  Avill  be  noticed  b}'  the  pa- 
tient so  long  as  his  e^-es  are  fixed  on  objects  above  the 
horizontal  mesial  line. 

The  Hympfoms  which  characterize  pais}"  of  this  muscle 
are,  that  whenever  an  attempt  is  made  to  look  down- 
wards, the  affected  eye  is  drawn  slightly  upwards  and 
inwards,  and  the  patient  has  homonymous  diplopia,  the 
false  object  appearing  to  the  outer  side  and  below  the 
level  of  the  true  one,  and  slanting  towards  it.  The  in- 
terval between  the  true  and  false  impressions,  both  in 
latitude  and  elevation,  are  increased  as  the  globe  is  ver- 
tically depressed. 

The  Sixth  Nerve — aJnlKeens — crosses  the  cavernous 
siuus,  lying  close  against  the  outer  side  of  the  internal 
carotid  arter3\  It  enters  the  orbit  through  the  sphenoidal 
fissure,  passing  between  the  two  heads  of  the  external 


310  I'AK. \ LYSIS    OF    MUSCLES    OF    THE    EYE. 

rectus,  to  the  ocular  surface  of  which  muscle  it  is  dis- 
tributed. In  its  passage  through  the  cavernous  sinus,  it 
receives  s^^mpathetic  filaments  from  the  carotid  plexus, 
and  a  branch  from  Meckel's  ganglion.  The  function  of 
the  sixth  nerve  is  entirely  motor. 

In  pcn-alysis  of  the  sixth  nerve  there  is  a  marked  in- 
ternal strabismus;  the  e3-e,  when  the  palsy  is  complete, 
cannot  be  drawn  outwards  beyond  the  mesial  line  of  the 
orbit,  but  it  can  be  turned  freely  in  all  other  directions. 
There  is  homonymous  diplopia,  the  false  image  being 
projected  to  the  outer  side  of  the  true  one.  If,  with  the 
sound  eye  closed,  the  patient  endeavors  to  seize  an  object, 
he  misses  his  aim,  the  hand  passing  to  its  outer  side.  In 
walking,  he  generally  turns  his  head  rather  towards  the 
side  opposite  to  that  of  the  affected  ej'e,  so  as  to  avoid 
the  diplopia  by  not  looking  outwards. 

From  cerebral  disease  or  from  tumors  of  the  orbit,  all 
the  ocular  muscles  ma}-  be  paralyzed;  the  eye  is  then 
rendered  prominent  and  stationary  in  the  centre  of  the 
orbit. 

The  p7'ognosis  of  the  paralytic  affections  of  the  mus- 
cles of  the  eye,  is  determined  b}'  the  following  considera- 
tions. 

a.  Tlie  Cause  of  the  FaraJi/sis. — When  the  loss  of  power 
pi'oceeds  from  some  syphilitic,  rheumatic,  or  gout}'  dis- 
ease, or  from  some  reflex  irritation,  the  prospect  of  re- 
covery, under  suitable  remedies,  is  favorable.  When, 
however,  the  paralysis  arises  fi'om  intra-cranial  mischief, 
and  is  associated  with  other  cerebral  symptoms,  the  prog- 
uosis  is  bad. 

y5.  TJie  Extent  of  the  Pcn-ohjsis,  whether  it  is  partial  or 
complete,  or  confined  to  the  muscles  supplied  by  one 
nerve,  is  an  important  point  to  decide.  The  prognosis  is 
alwavs  most  favorable  when  the  paralysis  is  partial  and 


PARALYSIS    OF    THE    SIXTH    NERVE.  311 

limited  to  one  ocular  nerve,  and  when  there  are  no  other 
symptoms  of  disease  of  the  nervous  system. 

y.  The.  length  of  time  the  Paralysis  has  lasted. — If  the 
loss  of  power  has  been  persistent,  and  no  improvement 
has  taken  place  in  spite  of  judicious  treatment,  the  prog- 
nosis is  unfavorable.  There  are,  however,  man}^  cases  in 
which  recovery  progresses  to  a  certain  point,  and  tlien 
ceases ;  tlie  paralyzed  muscle  does  not  completely  regain 
its  former  tone,  and  a  sliglit  strabismus  with  diplopia 
remains.  For  such  patients  much  may  be  done  by  local 
treatment. 

Treatment. — If  the  paral^'sis  is  due  to  s^'pliilis,  rheuma- 
tism, or  gout,  the  patient  must  be  treated  constitutionally, 
with  tlie  medicines  suited  to  these  special  diseases.  In 
most  cases  benefit  is  gained  from  small  and  repeated 
doses  of  the  iodide,  or  the  iodide  and  bromide  of  potas- 
sium (F.  74,  77),  or  of  the  iodide  of  potassium  combined 
with  iron  (F.  73).  The  bowels  should  be  freel}^  oiaened  by 
a  purgative ;  and  counter-irritation  may  be  used  behind 
the  ear,  either  by  rubbing  in  a  stimulating  liniment,  or 
by  applying  a  small  blister.  In  syphilitic  cases,  pil.  hy- 
drarg.  subchloridi  comp.  gr.  5,  may  be  given  every  other 
night  for  a  short  time,  or  a  little  of  the  unguent,  hydrarg. 
may  be  rubbed  night  and  morning  into  the  temple  of  the 
affected  e^'e.  Where  reflex  irritation  may  be  reasonably 
expected  to  be  the  cause  of  the  paralysis,  as  in  certain 
cases  of  palsy  of  the  sixth  nerve,  the  source  of  the  mis- 
chief must  be  sought  for  in  some  functional  derangement 
of  abdominal  viscera.  The  important  connection  between 
the  sixth  nerve  and  the  sj^mpathetic  is,  I  think,  quite  suf- 
ficient to  account  for  its  being  prejudicially  influenced  by 
visceral  irritation. 

To  relieve  the  diplopia,  which  is  so  distressing  to  the 
patient,  the  aflTected  eye  should  be  excluded,  either  by 
being  covered  with  a  bandage,  or  by  the  use  of  a  pair  of 


312  PARALYSIS    OF    MUSCLES    OF   THE    EYE. 

spectacles  witli  large  curved  glasses,  one  of  wliich  has 
been  completel}'  darkened.  In  certain  cases,  prisms  are 
of  the  greatest  service  in  uniting  the  double  images,  but 
it  must  be  remembered,  in  using  them,  that  they  will 
have  to  be  repeated!}^  changed,  as  the  palsied  muscle  re- 
gains its  power.  For  the  internal  strabismus,  from  para- 
lysis of  the  external  rectus,  the  prism  must  be  placed 
with  its  base  outicards ;  and  for  the  external  strabismus, 
from  paralj'sis  of  the  internal  rectus,  the  prism  must  be 
used  with  its  base  inwards. 

When  the  paralysis  is  probably  dependent  on  a  local 
affection  of  the  nerve,  as  from  some  rheumatic  or  gouty 
effusion,  fai'adization  is  often  of  the  greatest  service,  but 
it  should  not  be  recommejided  if  there  is  any  reason  to 
suspect  cerebral  disease. 

Under  one  or  other  of  the  methods  of  treatment  I 
have  described,  the  majority  of  the  cases  of  palsy  of  one 
of  the  ocular  nerves  will  steadily  progress  to  complete 
recover3\  There  are,  however,  occasionallj^  instances 
when  the  remedies  fail,  and  the  muscle  having  regained 
a  certain  amount  of  power  ceases  to  improve.  When  this 
happens,  and  the  strabismus  and  diplopia  haA'e  continued 
stationar}'  for  some  months,  an  operation  maj'  be  per- 
formed with  advantage,  to  restore  the  balance  of  power 
between  the  muscles.  If  the  paralytic  strabismus  be  di- 
vergent, the  external  rectus  may  be  divided ;  and  should 
this  fail,  the  internal  rectus  may  be  brought  forward, 
as  recommended  in  the  article  Strabismus,  page  293.  If, 
however,  the  remaining  strabismus  be  convergent,  the 
internal  rectus  must  be  divided. 


FOREIGN    BODIES    WITHIN    THE    EYE.  313 


CHAPTER  yill. 

special  injuries  of  the  eye. 
foreign  bodies  within  the  eye. 

The  lodgement  of  a  foreign  body  within  the  Eye 
is  one  of  the  most  serious  injuries  which  can  happen  to 
that  organ,  and  tlie  importance  of  ascertaining  correct!}', 
as  soon  as  possible  after  the  infliction  of  an  injur}-, 
wliether  there  is  a  foreign  body  within  it,  cannot  be  over- 
estimated. The  prognosis  of  the  case  rests  entirely  on 
the  elucidation  of  this  one  point. 

Every  penetrating  wound  of  the  globe  should  be  spe- 
cially examined  witli  reference  to  the  possibility  of  tliere 
being  a  foreign  body  within  the  eye. 

The  dangers  of  a  foreign  bod}^  within  the  eye  are : 

1.  The  risk  of  the  eye  beiug  completel}'  destroyed  by 
the  inflammation  which  its  presence  may  excite. 

2.  If  the  eye  has  been  destro^'ed  by  the  inflammatory 
action  which  the  foreign  body  has  induced,  the  stump,  or 
that  which  remains  of  the  eye,  will  be  liable  to  repeated 
attacks  of  inflammation  so  long  as  the  foreign  body  con- 
tinues imbedded  in  it;  and  with  each  attack  there  will  be 
an  increased  danger  of  the  other  eye  becoming  afl[ected 
with  sympathetic  ophthalmia. 

All  the  evidence  we  can  collect  ma}^  be  in  favor  of  there 
being  a  foreign  body  within  the  eye ;  3'et  if  we  cannot  see 
it,  and  we  have  no  reason  to  believe  that  it  is  buried 
within  the  lens,  we  must  wait  for  symptoms,  and  treat 
them  as  they  arise.  The  progress  of  the  case  will,  as  a 
rule,  quickly  determine  whether  there  is  a  foreign  body 


314  SPECIAL    INJURIES    OF   THE    EVE. 

within  the  e^'e,  although  in  some  exceptional  instances  it 
excites  but  little  if  any  irritation. 

The  symptoms  which  strongly  favor  the  presumittion 
that  a  foreign  body  is  within  the  eye  when  a  careful  ex- 
amination fails  to  detect  it,  are  : 

a.  An  increase  or  a  continuance  of  the  inflammation 
primarily  excited  by  the  injury  in  spite  of  all  the  reme- 
dial agents  which  may  have  been  used  to  arrest  it. 

/5.  If  the  first  inflammator}'  symptoms  have  subsided, 
the  continuance  of  a  subacute  choroido-iritis  or  choroido- 
retinitis,  uninfluenced  by  proper  local  and  constitutional 
treatment. 

y.  The  non-union  of  the  corneal  wound,  when  the 
cornea  has  been  the  part  of  the  eye  involved  in  the  in- 
jury;  or  the  only  partial  closure  of  the  wo'und,  leaving 
a  fistula  through  which  there  is  a  constant  drain  of 
the  aqueous,  causing  the  iris  to  lie  in  contact  with  the 
cornea. 

8.  Severe  and  continued  pain  in  the  e3'e,  unpropor- 
tioned  to  the  apparent  existing  inflammation,  and  un- 
alleviated  by  the  ordinary  local  applications  and  medi- 
cines. 

Treatment  of  For-eign  Bodies  xcithin  the  Eye. — In  all 
cases  of  foreign  body  within  the  eye,  the  treatment  un- 
doubtedly is — if  it  can  be  seen  and  the  removal  of  it  is 
practicable — to  take  it  awa}^  But  the  object  may  be  so 
placed  that  it  can  be  seen,  yet  from  its  situation  an  at- 
tempt to  remove  it  will  incur  a  risk  of  loss  of  the  eye, 
or,  from  the  difficulty  of  reaching  it,  the  operation  will 
probablj'  fail.  How,  then,  should  we  act  ?  M}'  answer 
to  this  is : 

1.  If  it  is  creating  irritation,  endeavor  to  remove  it,  as, 
though  failure  may  be  the  result,  jet  a  chance  has  been 
afforded  to  the  eye,  which,  had  it  been  successful,  might 
have  saved  it. 


INJURIES    OF    THE    EYE    FROM    ESCHAROTICS.       315 

In  all  cases  where  the  surgeon  deems  it  right  to  at- 
tenii)t  the  removal  of  a  foreign  body  from  within  the  eye, 
he  ought  to  have  a  discretionary  power,  that  if  he  fail 
to  find  it,  he  may  remove  the  globe  whilst  the  patient 
is  still  under  chloroform,  if  ciix-umstances  render  it  ad- 
vii>aljle. 

2.  If,  however,  the  foreign  body  is  creating  no  irrita- 
tion, and  there  is  a  fair  amount  of  vision,  and  an  attempt 
to  remove  it  would  greatly  hazard  the  eye,  it  shoidd  be 
left  alone  ;  but  the  patient  should  be  either  kept  under 
constant  observation,  or  be  cautioned  that  as  soon  as  any 
symptoms  of  irritation  show  themselves,  either  in  the  in- 
jured or  the  sound  e^'e,  he  must  seek  the  aid  of  his  sur- 
geon. 

In  every  case  wdiere  the  eye  is  destroyed  for  visual 
})urposes  by  the  inflammation  induced  by  a  penetrating 
wound,  and  there  is  reason  to  believe  that  a  foreign  body 
is  lodged  within  the  globe,  the  only  treatment  to  be 
adopted  is  to  excise  it.  It  has  ceased  to  be  an  organ 
of  vision,  and  at  some  future  period  it  may,  and  very  ; 
probably  will,  become  a  source  of  much  danger  to  the  f 
sound  e3'e. 

INJURIES    OF    THE    EYE    FROM    ESCHAROTICS. 

Quick.  Lime,  or  lime  before  it  has  been  slaked  by  the 
addition  of  water,  is  the  most  destructive  agent  that  can 
come  in  contact  with  the  surface  of  the  eye.  If  it  is  in 
sufficient  quantity,  and  is  allowed  to  remain  long  enough 
in  apposition,  absolute  destruction  of  the  part  ensues,  a 
slough  follows,  and  complete  loss  of  the  eye  is  a  not  in- 
frequent result.  In  the  smallest  quantity  it  is  a  most 
powerful  irritant ;  a  spasmodic  contraction  of  the  orbicu- 
laris tightly  closing  the  lids  upon  the  globe,  and  a  copious 
flow  of  tears  follow  the  introduction  of  even  a  particle  of 


316  SPECIAL   INJURIES    OF   THE    EYE. 

lime  into  the  eye.  The  epithelium  is  at  once  whitened 
and  destroyed,  aud  a  sharp  clear  line  will  indicate  the 
boundary  of  the  part  which  has  been  aflected  b}"  the  lime ; 
outside  this  boundary  the  conjunctiva  is  excessively  red 
and  more  or  less  chemosed ;  and  the  lids,  if  the  injury  is 
severe,  are  oedematous. 

If  the  epithelium  only  is  destroyed,  it  will  be  replaced, 
and  no  markings  of  the  injury  will  remain  ;  but  it  is  sel- 
dom, if  ever,  that  the  action  of  unslaked  lime  is  thus 
limited ;  the  Mhole  thickness  of  the  tissue  with  which  it 
comes  in  contact  is  usuall}'  destro3'ed  b}'  it,  and  dense 
contracted  cicatrices  are  the  result. 

Mortar,  Lime,  Plaster,  and  the  other  combinations 
of  lime  used  for  building  purposes,  differ  only  in  degree 
from  lime  in  the  way  in  which  the}'  affect  the  eye.  Their 
action  is  not  quite  so  rapid  or  so  acute  as  unslaked  lime  ; 
still,  if  the}'  are  allowed  to  remain  a  sufficient  time  in 
contact  with  the  eye  or  with  the  conjunctiva  of  the  lids, 
similar  results  are  produced  ;  sloughs  may  be  formed, 
and  suppuration  ending  in  complete  destruction  of  the 
eye  may  follow. 

Treatment  of  Injuries  from  Lime,,  Mortar,,  &c. — The 
first  course  to  be  adopted,  is  to  remove  as  quickly  as  pos- 
sible erer}'  particle  of  lime  from  the  e^e,  and,  at  the  same 
time,  to  arrest  the  further  destructive  action  of  anj*  frag- 
ments which  maA'  be  still  sticking  to  the  conjunctival 
epithelium.  For  this  purpose,  a  little  sweet  oil  should  at 
once  be  dropped  into  the  e^e,  and,  the  upper  and  lower 
lids  being  everted  in  turn,  the  bits  of  lime  should  be 
gently  lifted  away  with  a  fine  sjiatula  or  spud.  Having 
removed  all  that  can  be  seen,  the  upper  lid  being  everted 
and  the  lower  one  drawn  down  b}'  the  finger  of  an  assist- 
ant, a  stream  of  tepid  water  should  be  gently  syringed 
over  the  front  of  the  eye  and  the  inner  surfaces  of  the 


BURNS    AND    SCALDS    OF    THE    EYE.  317 

litis,  SO  as  to  wash  away  an_y  small  pieces  which  may  have 
escaped  notice  ;  but,  before  closing  the  lids,  two  or  three 
more  drops  of  oil  should  be  dropped  into  the  eye.  If 
the  patient  is  seen  b}'  the  surgeon  ve7'y  earHy  after  the 
accident,  the  eye  may  be  s^a-inged  out  with  a  little  weak 
vinegar  and  water,  or  the  dilute  acetic  acid  and  water, 
about  the  strength  of  one  drachm  to  one  and  a  half  ounces 
of  water.  An  acetate  of  lime  is  thus  formed,  which  is 
innocuous  ;  but,  for  this  treatment  to  do  good,  it  must  be 
resorted  to  immediately  after  the  introduction  of  the  lime ; 
and,  as  such  a  chance  is  rarel}^  attbrded  the  surgeon,  the 
use  of  olive  oil  in  the  first  instance  will  generally  be  found 
preferable.  For  the  first  two  or  three  days  after  the  in- 
jur^',  soothing  applications  are  best  suited,  and  the  cold 
water  dressings  to  the  e^^e  should  be  continued,  or  a  lo- 
tion of  belladonna  may  be  substituted  if  the  eye  is  very 
painful.  Opiates  should  be  given  at  night  if  the  pain  pre- 
vents sleep. 

Burns  and  Scalds  op  the  Eye. — Hot  fluids,  accord- 
ing to  the  intensity  of  their  heat,  redden,  vesicate,  or 
even  destroy  the  conjunctival  surface  of  the  eye  or  lids 
with  which  the}"  come  in  contact.  They  produce  the 
same  immediate  eflTect  on  the  conjunctiva  of  the  eye  as 
they  do  on  the  skin  covering  the  body.;  but  the  delicacy 
of  the  textures  of  the  eye,  and  the  importance  of  the  in- 
tegrity of  each  for  the  well-doing  of  the  whole,  render 
what  would  be  a  slight  scald  elsewhere,  a  severe  injury 
to  the  eye. 

Treatment. — When  the  patient  is  first  seen,  a  few  drops 
of  olive  oil  should  be  dropped  into  the  e^^e,  the  lids  should 
be  then  gently  closed,  and  some  cotton-wool  laid  loosely 
over  them,  which  should  be  kept  in  its  place  b}'  a  single 
turn  of  a  light  bandage. 

The  dropping  of  oil  into  the  eye  may  be  repeated  two 
27* 


318  SPECIAL   INJURIES    OF   TUE    EYE. 

or  three  times  during  the  (lay,  and  each  time  the  bandage 
is  removed,  the  eye  and  lids  shoukl  be  waslied  with  a  gl^-- 
cerine  lotion  (F.  44),  free  of  any  discharge  which  may 
have  accumulated. 

If  the  lids  are  severely  burnt  or  scalded,  previously  to 
applying  the  cotton-wool,  lint  soaked  in  carron  oil  or  equal 
parts  of  lime-water  and  linseed  oil,  should  be  laid  over 
them  ;  but,  if  the  burn  or  scald  is  oul^'  slight,  a  little  ung. 
cetacei  on  lint  will  be  sufficient.  Opiates  should  be  given 
internall}'  if  the  patient  is  suffering  much  pain  :  they  not 
only  give  ease  and  procure  slee}),  but  the}^  exercise  a 
specially  beneficial  control  over  the  suppurative  action 
which  has  to  follow. 

Strong  Sulphuric  and  Nitric  Acids  act  chemically 
on  the  tissues  of  the  e^^e,  and,  if  in  sufficient  quantity, 
cause  disorganization  of  the  parts  with  which  they  are 
brought  in  contact,  producing  superficial  or  deep  sloughs. 

The  action  of  a  strong  acid  on  the  eye,  even  in  the 
smallest  quantity,  is  that  of  a  powerful  irritdflt ;  it  pro- 
duces great  pain  and  smarting,  more  or  less  oedema  of  the 
lids,  and  a  constant  flow^  of  tears,  with  intolerance  of 
light,  which  may  last  for  many  days,  even  though  the 
actual  injury  inflicted  does  not  extend  beneath  the  epithe- 
lium of  the  ocular  conjunctiva. 

The  rapid  flow  of  tears,  however,  which  the  irritation  of 
the  acid  instantly  excites,  quickl}'  dilutes  it ;  and  if  it  is 
only  a  drop  or  a  small  splash  which  has  entered  the  eye, 
the  injur}'  which  it  inflicts  is  comparatively  slight  and 
completel}^  remediable. 

Treatment  of  Injuries  from  strong  Acids. — If  the  pa- 
tient is  seen  verj^  shortly  after  the  accident,  the  e3'es 
should  be  gently  syringed  out  with  some  weak  alkaline 
solution,  such  as  potasste  bicarb,  or  soda"  sesquicarb.  gr. 
5,  aqute  destillat.  s  1,  to  neutralize  any  acid  which  may 


INJURIES    FROM    ACIDS.  319 

yet  remain  ;  or  if  this  cannot  be  at  once  obtained,  tepid 
water  sliould  be  used.  A  little  olive  oil  should  be  then 
drop[)ed  iuto  the  eye,  and  this  may  be  repeated  two  or 
three  times  a  da}^  if  it  gives  ease.  The  lids  being  closed, 
a  layer  of  cotton-wool  should  be  laid  loosely  over  them, 
and  a  single  turn  of  a  bandage  passed  round  the  head  to 
keep  it  in  its  place. 

When  the  lids  are  much  burnt  with  a  strong  acid,  an 
alkaline  dressing  should  be  used  for  the  first  twenty-four 
hours,  and  lint  dipped  in  the  liniment,  calcis  cnm  creta 
(F.  29),  should  be  laid  over  them,  then  a  layer  of  cotton- 
wool, and  a  turn  of  a  bandage  over  the  whole  to  keep  all 
in  situ.  The  ordinary  carron  oil  or  equal  parts  of  lime- 
water  and  linseed  oil,  may  be  afterwards  substituted  for 
the  chalk  dressing,  and  continued  until  the  sloughs  begin 
to  separate. 

YiNEGAR,  DILUTE  AcETic  AciD,  Or  any  of  the  weak  or 
dilute  acids,  act  as  irritants  to  the  eye  ;  and  although  they 
do  not  immediately-  destroy  any  of  the  tissues  with  which 
the}^  may  be  brought  into  contact,  yet  they  often  give  rise 
to  an  ophthalmia  which  is  the  cause  of  much  suffering, 
and  in  some  instances  even  of  danger  to  the  eye.  The 
primary  treatment  recommended  in  the  cases  of  injury 
from  strong  acids  is  equally  applicable  to  those  occa- 
sioned b}^  the  weak  or  the  dilute.  If  seen  early,  the  al- 
kaline solution  should  be  used,  and  afterwards  either 
soothing  or  astringent  applications,  to  allay  irritation, 
and  to  check,  if  necessary,  undue  secretion  from  the  con- 
junctiva. In  all  injuries  to  the  eyes  from  chemical  agents, 
a  solution  of  the  antidote  should  be  first  used,  if  the  pa- 
tient is  seen  sufltlcientl}'  early  to  render  its  application  of 
service.  As  in  the  cases  of  injury  from  an  acid,  an  alka- 
line solution  was  recommended ;  so  in  those  from  a  strong- 
alkali,  such  as  caustic  potash  or  soda,  an  acid  solution  of 


320  SPECIAL    INJUUIKS    OF    THE    EYE. 

one  drachm  of  vinegar,  or  of  the  dihite  acetic  acid,  to  tiie 
ounce  of  water,  should  be  syringed  over  the  front  of  the 
eye  and  palpebral  surfaces  of  the  lids. 

INJURIES  FROM  PERCUSSION  CAPS,  GUNPOWDER,  AND  SMALL 

SHOT. 

rercussion  Caps. — One  of  the  most  frequent  sonrces  of 
injuries  to  the  eye  from  the  use  of  guns,  which  is  met  with 
in  civil  practice,  is  from  fragments  of  percussion  caps 
fl^'ing  otf  when  they  are  exploded  b}*  the  hammer  of  the 
gun.  This  accident  very  rarely  happens  when  the  cai)s 
are  of  the  best  quality,  such  as  are  sold  b}^  respectable 
gunsmiths  for  ordinary  sporting  purposes.  It  is  almost 
invariably  occasioned  b}'  toj'  guns,  bought  as  playthings 
for  children,  or  used  by  itinerants  at  fairs  and  other  places 
of  public  resort,  for  firing  at  a  target  for  nuts.  These 
common  percussion  caps  are  sold  at  a  very  low  price,  and 
are  made  of  a  brittle  alloj^  instead  of  the  best  copper.  In 
their  explosion  small  scales  are  detached  from  them  and 
driven  with  such  velocity  that  if  the}'  strike  the  eye  they 
usually  penetrate  it.  Unfortunately,  the  victim  of  such 
accidents  is  more  frequently  some  bystander  or  passer-by 
than  the  person  who  is  shooting.  In  nearlj^  everj-  case, 
total  loss  of  the  eye  is  the  ultimate  result  of  the  injur}^, 
and  in  several  which  have  come  under  my  care,  the  end 
has  been  still  moi-e  disastrous ;  the  other  eye  has  become 
aflected  with  sympathetic  ophthalmia,  and  it  also  has  been 
irreparabl}^  destroyed. 

Treatment. — See  Treatment  or  Foreign  Bodies  in 
THE  Eye,  page  314. 

Gunpowder. — The  near  explosion  of  gunpowder  may 
affect  the  eye  in  four  different  ways : 

1.  By  the  concussion  it  produces  when  exploded  in 
close  contiguity  to  the  eye. 


GUNPOWDER.  321 

2.  From  the  burning  or  scorching  of  the  surface  of  the 
ej'e,  and  the  lining  membrane  of  the  lids. 

3.  From  depositing  in  the  external  tissues  of  the  eye 
specks  of  unexploded  powder. 

4.  From  grains  of  powder  being  driven  with  suflicient 
force  to  penetrate  the  globe. 

Treatment  of  Gunpowder  Injuries. — The  first  object  is 
to  remove  all  loose  powder,  if  there  is  an}',  from  the  sur- 
face of  the  eje,  and  from  between  the  lids  and  the  globe. 
This  ma}'  be  done  by  everting  the  lids  and  gentl}^  squirt- 
ing a  stream  of  tepid  water  over  the  front  of  the  e3'e,  and 
the  conjunctiva  of  the  lids,  with  a  syringe,  or  small  India- 
rubber  bottle,  and  afterwards  hy  lifting  away,  with  a  fine 
s})atula  or  small  scoop,  any  particles  of  powder  which  may 
be  adherent  from  being  entangled  with  mucus,  or  with 
the  conjunctival  epithelium.  The  cornea  should  be  then 
carefully  examined,  and  all  the  unexploded  grains  which 
may  be  found  imbedded  in  it  should  be  removed  with  a 
fine  needle  or  spud.  Those  grannies  which  are  lodged 
deepl}^  in  the  true  corneal  tissue,  and  are  out  of  the  field 
of  vision,  may  be  left  if  thej^  cannot  be  easil}^  lifted  away, 
as  more  harm  will  be  done  by  injudiciously  picking  at 
them  than  their  presence  can  excite. 

Specks  of  unexploded  powder  which  are  lying  on  the 
sclerotic  surface  of  the  eye  may  be  removed,  but  no  great 
effort  should  be  made  to  detach  them,  as,  beyond  the 
slightly  unseemly  appearance,  they  seldom,  if  ever,  do 
harm. 

Having  taken  awa}'  all  the  unexploded  powder,  a  little 
castor  or  olive  oil  should  be  dropped  into  the  eye,  and 
soothing  applications  used  externally.  A  lotion  of  bella- 
donna (F.  32)  will  relieve  pain,  and  b}'  keeping  the  pupil 
dilated  act  beneficially  in  case  an}-  general  inflammation 
of  the  ej'e  should  follow. 


322  SPECIAL    INJURIES    OF   THE    EYE. 

Injuries  from  Small  Shot,  commonly  used  for 
Sporting  Purposes. — The  velocity  and  direction  of  the 
shot  when  it  strikes  the  eye  determine  very  mnch  the  ex- 
tent of  the  injury  which  it  inflicts. 

1.  S2:>ent  Shots. — If  the  shot  is  vcarhj  f^penf,  it  may 
merely  produce  a  slight  concussion  with  ecchyniosis  of 
the  conjunctiva,  from  which  the  eye  may  quickly  recover. 
If,  however,  there  should  be  some  irritation,  it  may  gen- 
erally be  subdued  b}'  the  application  of  two  leeches  to  the 
temple,  the  use  of  the  belladonna  lotion  to  the  eye,  and 
a  few  days'  absolute  rest. 

2.  Glaiwmg  Shots. — A  shot  at  full  speed  may  strike  the 
eye  in  its  transit  without  penetrating  it,  and  leave  a  deep 
furrow,  which  may  very  closely  resemble  a  penetrating 
Avonncl. 

3.  Penetrating  Shots. — The  lodgment  of  a  shot  within 
the  e3^e  will  produce  all  the  severe  symptoms  which  have 
already  been  described  in  the  section  on  Foreign  Bodies 
AViTiiiN  THE  Eye.  As  a  rule,  the  eye  may  be  considered 
as  lost  after  such  an  accident.  The  passage  of  the  shot 
into  the  eye  generally  inflicts  such  irreparable  damage  on 
the  different  tissues  through  which  it  passes,  that  all  sight 
is  at  once  extinguished.  The  eye  at  first  becomes  acutely 
inflamed,  and  occasionally  suppui-ates  ;  but  generally  the 
acnte  s^nnptoms  subside,  and  a  low  form  of  deep-seated 
inflammation  sets  in,  which  ends  in  softening  and  shrink- 
ing of  the  globe.  So  long,  however,  as  the  shot  remains 
within  the  eye,  it  is  a  constant  source  of  danger,  and  may 
at  any  time  give  rise  to  an  attack  of  s3-mpathetic  oph- 
thalmia in  the  sound  eye,  which  may  cause  its  destruc- 
tion. See  Treatment  of  Foreign  Bodies  -within  the 
Eye,  p.  314. 


EXCISION.  323 


EXCISION    OF    THE    EYE. 

The  patient  shoiild  lie  on  his  back  on  a  couch  with  his 
face  towards  the  light,  and  the  eyelids  be  separated  by 
the  stop-spring  speculum.  With  a  pair  of  fine  single- 
toothed  dissecting  forceps  a  fold  of  the  con- 
junctiva and  subjacent  fascia  is  to  be  seized 
close  to  the  cornea,  and  divided  wuth  a  pair  of 
blunt-pointed  scissors,  curved  on  the  flat,  as  in 
Fig.  31.  Through  this  opening  one  blade  of 
the  scissors  is  to  be  passed,  whilst  the  other  re- 
mains external  to  the  e3^e,  and  then  with  a  few 
clips  the  conjunctiva  and  fascia  covering  the 
globe  are  to  be  cut  through  in  a  circle  around 
the  cornea.  An  ordinary  strabismus-hook  (Fig. 
29,  p.  290)  is  then  to  be  introduced  in  turn  be- 
neath the  tendons  of  each  of  the  recti  mus- 
cles, which  are  to  be  divided  with  the  scissors 
close  to  their  insertions  in  the  sclerotic. 

Having  made  certain  that  the  recti  muscles 
are  completely  divided,  one  finger  of  each  hand 
should  press  back  the  tissues  on  either  side  of  the  e^-^e, 
so  as  to  push  the  globe  forwards  and  partiall}^  dislocate 
it  through  the  opening  which  was  made  in  the  conjunc- 
tiva at  the  commencement  of  the  operation.  By  this 
simple  mano3uvre,  the  next  step,  the  division  of  the  optic 
nerve,  is  facilitated.  The  cut  end  of  the  tendon  of  either 
the  internal  or  external  rectus  muscle  should  now  be 
seized  with  the  forceps,  and  the  e3'e  drawn  over  to  one 
side,  whilst  the  scissors,  with  the  blades  shut  and  the 
curve  towards  the  globe,  are  passed  backwards  between 
it  and  the  surroumding  tissues.  As  they  round  the  j^os- 
terior  curve  of  the  eye,  the  blades  should  be  opened, 
when,  after  gently  urging  them  a  little  further  onwards, 
the  optic  nerve  will  come  within  their  grasp,  and  may  be 


324  SPECIAL    INJURIES    OF   THE    EYE, 

then  divided.  The  eye  may  now  be  lifted  with  the  fingers 
forwards,  and  the  obliqne  mnseles,  or  any  other  tissues 
which  may  be  still  adherent,  cut  through  with  the  scis- 
sors, and  the  operation  will  be  completed. 

When  all  the  bleeding  has  ceased,  the  opening  in  the 
conjunctiva,  through  which  the  eye  has  been  enucleated, 
may  be  closed  by  drawing  the  edges  together  with  a  fine 
thread,  which  is  passed  through  them  at  different  points 
and  then  tied.  This  is  a  finish  to  the  operation,  and 
gives  an  appearance  of  neatness  to  it  at  the  time.  It  is 
not,  however,  essential,  as  the  parts  are  afterwards  com- 
i:)letely  drawn  together  b}-  cicatrization.  In  the  excision 
of  inflamed  e3'es  it  is  positivel}^  prejudicial,  as  it  prevents 
the  free  escape  of  inflammatory  exudations,  and  thus  favors 
orbital  cellulitis. 

Treatment  after  Excision  of  the  Eye. — As  a  rule,  the 
patient  recovers  so  rapidl}^  from  this  operation  that  but 
little  after-treatment  is  required.  A  fold  of  wet  lint  should 
be  kept  over  the  lids,  and  all  discharge  from  the  wound 
carefully  washed  away  from  time  to  time  with  a  little  warm 
water  gentl}^  sj'ringed  into  the  orbit  with  a  glass  S3'ringe. 
The  wound  usuall}'  cicatrizes  in  from  three  days  to  a  week, 
but  a  slight  muco-purulent  discharge  from  the  orbit  often 
continues  for  two  or  three  weeks  afterwards.  This  may 
be  checked  by  a  lotion  of  alum  or  tannic  acid  (F.  38,  47), 
which  should  be  used  with  a  syringe  three  or  four  times 
daily.  It  frequentl}"  happens,  that  on  looking  into  the 
orbit  the  cause  of  the  continuance  of  the  discharge  may 
be  seen  in  a  small  fungoid  granulation  sprouting  from 
the  cicatrix  of  the  conjunctiva.  This  should  be  removed 
by  a  single  snip  with  a  pair  of  curved  scissors. 

If,  however,  instead  of  progressing  thus  favorabl}', 
symptoms  of  orbital  cellulitis  come  on,  warmth  should 
be  applied  to  the  wound  by  frequent  fomentations  of 
hot  water  or  decoction  of  poppy -heads,  and  afterwards 


ARTIFICIAL    EYES,  325 

by  a  liuseed-meal  poultice  over  the  lids  and  brow.  If  the 
opening  in  the  conjunctiva  has  been  closed  by  a  suture, 
it  should  be  at  once  removed.  It  is  good  practice  in  such 
a  case  to  make  a  free  incision  through  the  wound  in  the 
conjunctiva  into  the  cellular  tissue  of  the  orbit,  so  as  to 
give  free  vent  to  all  inflammatory  exudations  as  they  are 
effused.  B\'  thus  encouraging  suppuration  and  favoring 
the  exit  of  the  pus,  the  urgent  symptoms  will  probably 
be  at  once  relieved.  The  bowels  should  be  freely  acted 
on  by  a  purgative,  and  the  patient  should  be  kept  very 
quiet  in  a  darkened  room.  It  is  seldom  that  any  un- 
toward s3'mptoms  follow  the  operation  of  excision  of 
the  e3'e. 

Artificial  Eyes. — In  an  ordinary  case,  from  six  weeks 
to  two  months  after  the  operation  is  the  best  time  for 
commencing  the  use  of  a  glass  eye.  Time  should  be  al- 
lowed for  complete  cicatrization  to  be  effected,  and  for 
all  swelling  and  discharge  to  subside  before  an  artificial 
e^^e  is  introduced  within  the  orbit. 

One  of  the  most  frequent  inconveniences  produced  by 
too  soon  wearing  an  artificial  eye  is  a  chronic  conjuncti- 
vitis with  a  muco-purulent  discharge,  which  is  often  very 
troublesome  to  arrest.  Another  and  a  more  serious  an- 
noj'ance  is  an  inflammation  of  the  conjunctiva  and  sub- 
mucous tissue  in  the  line  on  which  the  edge  of  the  artificial 
eye  rests,  sometimes  going  on  to  ulceration.  As  the  re- 
sult of  this,  cicatrices  are  often  formed,  which  render  the 
adjustment  of  another  eye  very  difficult,  and  sometimes 
impossible. 

When  a  lost  eye  has  been  removed  on  account  of  the 
sound  one  suffering  from  sympathetic  ophthalmia,  an  arti- 
ficial e^'e  should  not  be  allowed  until  all  the  sympathetic 
symptoms  have  been  arrested,  and  the  eye  has  remained 
quiet  for  at  least  six  months. 

28 


326  ARTIFICIAL    EYES. 

The  following  excellent  rules  are  given  to  the  patients 
at  the  Ro3'al  London  Ophthalmic  Hospital  who  have  had 
the  misfortune  to  lose  an  eye. 

Instructions  for  Persons  wearing  an  Artificial 
Eye. — It  should  be  taken  out  every  night,  and  replaced 
in  the  morning. 

To  take  the  Eye  out. — The  lower  eyelid  must  be  drawn 
downwards  with  the  middle  finger  of  the  left  hand  ;  and 
then,  with  the  right  hand,  the  end  of  a  small  bodkin  must 
be  put  beneath  the  lower  edge  of  the  artificial  eye,  which 
must  be 'raised  gentl}^  forwards  over  the  lower  eyelid, 
Avhen  it  will  readily  drop  out.  At  this  time  care  must  be 
taken  that  the  eye  does  not  fall  on  the  ground,  or  other 
hard  place,  as  it  is  very  brittle,  and  may  easil^^  be  broken 
by  a  fall. 

To  put  the  Eye  in. — Place  the  left  hand  flat  upon  the 
forehead,  with  the  fingers  downwards,  and  with  the  two 
middle  fingers  raise  the  upper  ej-elid  towards  the  e3-e- 
brow,  then,  with  the  right  hand,  push  the  upper  edge  of 
the  artificial  eye  beneath  the  upper  eyelid,  which  may 
now  be  allowed  to  drop  upon  the  eye.  The  eye  must 
then  be  supported  with  the  middle  fingers  of  the  left 
hand,  whilst  the  lower  eyelid  is  raised  over  its  lower 
edge  with  the  right  hand. 

After  it  has  been  Avorn  dail}^  for  six  months,  the  pol- 
ished surface  of  the  artificial  eye  becomes  rough  ;  when 
this  happens,  it  should  be  replaced  by  a  new  one.  Unless 
this  is  done,  uneasiness  and  inflammation  ma}'  result. 


EPIPHORA.  327 


CHAPTER  IX. 

DISEASES    OF   LACHRYMAL   APPARATUS. 

Epiphora,  or  a  watery  ej'e,  is  an  overflow  of  tlie  tears. 
This  overflow  is  not  caused  by  an  undue  secretion  of  the 
lachrymal  gland,  but  by  some  imperfection  in  the  lach- 
rymal apparatus,  through  which  the  escape  of  the  tears 
is  retarded ;  the}^  consequently  accumulate  in  the  lacus 
at  the  inner  angle  of  the  eye,  and  from  tune  to  time  flow 
over  the  margins  of  the  lid  on  to  the  cheek.  The  ex- 
posure of  the  eye  to  cold  or  wind  aggravates  the  epiphora, 
by  stimulating  the  lachr3anal  gland  to  an  increased  secre- 
tion of  tears.     Epiphora  may  arise  : 

1.  From  a  displacement  of  the  punctum  loithout  any 
mechanical  obstruction  in  the  canaliculus,  lachr3'mal  sac, 
or  nasal  duct. 

a.  In  old  people  a  relaxed  orbicularis  frequenth^  allows 
the  lower  lid  to  fall  from  the  globe  and  become  slightly 
everted,  and  thus  to  draw  awa}^  the  punctum  from  its 
proper  position  with  respect  to  the  globe. 

/?.  A  similar  result  is  seen  in  lippitudo,  p.  342,  and  in 
all  cases  of  ectropion  of  the  lower  lid. 

2.  Obstruction  of  the  canaliculus  : 

a.  From  closure  of  its  opening  into  the  sac. 

/?.  From  some  foreign  body  (frequently  an  eyelash)  or 
from  a  small  chalky  concretion. 

y.  From  a  tarsal  cyst  or  stye  pressing  upon  the  canal- 
iculus. 

?>.  Obstruction  in  the  lachrymal  sac  or  nasal  duct : 

a.  From  blennorrhoea  or  chronic  inflammation  of  the  sac. 

yS.  From  dacryo-cystitis  or  acute  inflammation  of  the  sac. 


328  DISEASES    OF    LACHRYMAL    APPARATUS. 

f.  From  stricture. 

8.  From  mechaiiical  obstruction  by  tumors. 

Treatment. — As  epiphora  is  to  be  regarded  oidy  as  a 
symptom  of  derangement  in  some  part  of  the  lachrymal 
apparatus,  the  cause  must  be  first  detected,  and  then  en- 
deavors made  to  remove  it.  When  the  punctum  is  dis- 
placed, the  canaliculus  should  be  slit  up,  and  means 
should  be  taken  to  restore  the  lid,  if  diseased,  to  a 
healthy  state,  or,  if  everted,  to  its  normal  position. 

Foreign  bodies  or  concretions  in  the  canaliculus  should 
be  extracted.  Sometimes  this  can  be  accomplished  with 
the  aid  of  a  pair  of  iris  forceps  withov;t  any  cutting  oper- 
ation ;  but,  if  nol,  the  canaliculus  must  be  laid  open,  when 
all  difiiculty  will  be  removed.  The  treatment  of  the  other 
causes  of  epiphora  which  have  been  mentioned,  will  be 
found  under  their  respective  headings. 

Chronic  Inflammation  or  the  Lachrymal  Sac — 
BlennorrhcBa — Tumor  of  Sac — Mucocele — is  a  disease  of 
slow  progress  and  long  duration.  The  patient  generally 
is  unable  to  say  when  it  commenced,  so  long  has  he  suf- 
fered from  a  watery  eye ;  but  an  increase  in  the  severity 
of  the  symptoms  has  induced  him  to  seek  advice.  This 
is  the  tale  of  a  large  number  of  such  cases. 

Symptoms.  —  Constant  epiphora.  The  finger  placed 
over  the  membranous  portion  of  the  sac,  will  detect  a 
fulness,  sometimes  amounting  to  an  absolute  protuber- 
ance, and  a  moderate  pressure  on  this  will  cause  a  regur- 
gitation of  thick  viscid  mucus  or  muco-puruleut  secretion 
through  one  or  both  puncta.  The  degree  of  distension 
of  the  sac  varies  with  the  duration  and  severit}^  of  the 
disease.  In  some  cases  there  is  a  mere  thickening  and 
dilatation  of  the  upper  extremity  of  the  sac,  which  may 
be  felt  with  the  finger  just  below  the  tendo  palpebrarum  ; 
whilst  in  severe  and  long-standing  cases  the  sac  is  so  en- 


INFLAMMATION    OF    SAC. 


329 


Fig. 


largcd  as  to  be  expanded  along  the  border  of  the  orbit, 
and  to  appear  as  a  tumor  the  size  of  a  bean, 
corresponding  in  position  to  the  inner  half 
of  the  lower  lid.  From  the  constant  exuda- 
tion from  the  canaliculi,  the  eye  becomes  ir- 
ritable, the  caruncle  red,  and  the  edges  of 
the  lid  excoriated.  The  sight  is  also  fre- 
(piently  dimmed  from  films  of  mucus  floating 
in  the  tears  across  the  cornea,  and  the  pa- 
tient is  troubled  by  having  repeatedly  to  wipe 
away  the  accumulated  tears  from  the  inner 
angle  of  the  eye. 

Treatment. — The  first  course  to  be  pursued 
is  to  slit  up  the  canaliculi,  and  examine  with 
a  probe  the  lachrymal  sac  and  nasal  duct,  to 
determine  if  there  is  a  stricture  or  any  other 
change  in  the  mucous  track  to  account  for  the 
long-continued  obstruction  and  discharge. 

A  stricture  may  exist  in  three  places : 

a.  At  the  point  whex'e  the  canaliculus  joins 
the  sac. 

/3.  At  the  line  of  junction  of  the  lachrymal 
sac  with  the  nasal  duct. 

y.  Close  to  the  opening  of  the  nasal  duct 
into  the  nose. 

The  first  and  second  are  the  most  frequent 
sites  for  stricture. 

a.  A  stricture  at  the  point  where  the  ca- 
naliculus joins  the  sac,  is  recognized  by  the 
obstruction  the  probe  meets  with  as  it  is 
passed  onwards  ;  instead  of  entering  the  sac 
and  striking  against  the  internal  bony  wall 
of  the  canal,  its  progress  is  arrested  by  the 
outer  membranous  wall  of  the  sac,  which,  when  pressed 
upon  by  the  point  of  the  probe,  draws  inwards  the  mar- 

28* 


OoO  DISEASES    OF    LACHRYMAL    APPARATUS. 

gill  of  the  lid,  and  imparts  a  feeling  of  elastic  resilience. 
For  such  a  case,  the  following  course  should  be  adoi>ted. 
A  guarded  knife  should  be  passed  as  a  probe  along  the 
slit-up  canaliculus  until  it  reaches  the  sac,  when  failing 
to  iind  the  opening  of  the  duct,  the  guard  is  to  be  drawn 
back,  and,  with  a  little  pressure,  the  point  of  the  blade 
will  be  made  to  enter  the  membranous  portion  of  the 
canal.  A  free  opening  should  now  be  made  in  the  sac, 
and  the  knife,  having  been  withdrawn,  the  narrow  end 
of  a  Weber's  conical  sound  (Fig.  32),  should  be  passed 
through  the  wound  into  the  lachiTinal  canal.  The  pa- 
tient should  be  seen  daily  for  the  first  few  days  after  the 
operation,  and  afterwards  CAcry  third  or  fourth  day,  in 
order  to  insert  between  the  lips  of  the  wound  a  Weber's 
sound,  or  Bowman's  dilator  to  keep  the  opening  in  the 
sac  from  closing  during  the  cicatrizing  period, 

/?.  If  the  stricture  should  be  at  the  junction  of  the 
lachiymal  sac  with  the  nasal  duct,  a  probe  should  be  in- 
troduced twice  a  week  until  it  passes  with  fa- 
J'lG.  o3.  cility ;  or  the  narrow  end  of  Weber's  conical 
sound  ma}',  wdth  a  little  steady  pressure,  be 
urged  through  the  stricture,  and  hy  a  rapid  di- 
latation assist  the  progress  of  the  cure.  It  is  to 
these  cases  that  Dr.  Stilling's  plan  of  incising 
internally  the  mucous  membrane  of  the  lach- 
lymal  canal  seems  suitable.  The  canaliculus 
having  been  laid  open  in  the  usual  way,  he  first 
passes  a  Weber's  conical  sound  (Fig.  32),  to  as- 
certain the  position  of  the  stricture  and  also  to 
dilate  sufHcientl}'  the  opening  in  the  membran- 
ous sac  to  allow  of  the  easy  passage  of  his  knife  (Fig. 
33).  Having  withdrawn  the  sound,  he  introduces  his 
knife,  with  w-hich  he  incises  the  mucous  membrane  of  the 
canal  at  the  site  of  the  stricture  in  three  or  four  diflerent 
places  until  the  blade  can  be  freely  turned  in  all  directions. 


INFLAMMATION    OF    SAC.  331 

From  the  reported  eases,  the  success  of  this  treatment  is 
so  great,  that  frequently  no  further  passage  of  the  probe 
is  necessarj^  If  after  having  dilated,  the  stricture,  a 
muco-puruleut  discharge  continues,  the  sac  should  be 
washed  out  two  or  three  times  a  week  with  an  astringent 
lotion  (F.  38,  47). 

y.  When  the  constriction  is  at  the  lower  end  of  the 
nasal  duct  close  to  its  opening  into  the  nose,  the  stricture 
should  be  rapidly-  dilated  at  the  first  introduction  of  the 
probe  by  a  steady  forcible  pressure,  and  the  communica- 
tion with  the  nose  be  at  once  restored.  A  probe  should 
be  afterwards  passed  a  few  times,  at  interA'als  of  two  or 
three  da3^s,  to  keep  the  orifice  patulous. 

In  the  treatment  of  stricture  of  the  lachrymal  passage, 
it  is  seldom  necessary  to  use  stjdes.  Occasional!}',  how- 
ever, when  the  constriction  is  close  to  the  opening  of  the 
canaliculi,  they  will  be  found  of  service  ;  but  their  use 
should  not  be  continued  for  more  than  a  few  days.  The 
best  form  of  style  is  a  piece  of  silver  wire  of  the  thickness 
of  a  large-sized  probe,  cut  to  the  length  of  the  canal, 
rounded  at  one  extremity,  and  the  other  drawn  out  so 
finely  as  to  allow  of  its  being  bent  at  an  acute  angle  to  the 
shaft  to  prevent  its  slipping  into  the  sac.  Mr.  Couper 
speaks  favorably  of  probes  made  of  the  Laminaria  digi- 
tata,  which  he  has  used  to  dilate  the  stricture.  After 
their  introduction  they  rapidly  absorb  moisture  from  the 
canal,  and  swell  out  to  three  or  four  times  their  original 
size. 

In  those  cases  where  there  is  much  distension  of  the 
sac,  it  will  be  necessary  to  persevere  in  washing  out  the 
lachr^nnal  canal  with  an  astringent  injection,  and  at  the 
same  time  to  give  the  patient  some  slightl}'  stimulating- 
lotion  (F.  19,  20)  to  drop  twice  a  day  into  the  inner  angle 
of  the  eye.  By  steadily  continuing  this  treatment  the 
dilated  sac  will  usually  shrink  to  its  normal  dimensions. 


332  DISEASES    OF    LACHRYMAL   APPARATUS. 

On  two  occasions  where  the  membranous  portion  of 
the  canal  Avas  so  dilated  as  to  form  a  tumor  Avhich  ex- 
tended bej'ond  the  centre  of  the  loAver  lid,  I  cut  down 
upon  the  swelling,  and  excised  the  whole  of  its  expanded 
anterior  wall.  Both  patients  made  \evy  satisfactory  re- 
coAcries.  It  is  an  operation,  however,  which  is  never 
needed  except  in  extreme  cases. 

Acute  Inflammation  or  the  Lachrymal  Sac — Da- 
crijo-cyxtitis — usually  attacks  only  one  lachrymal  sac,  al- 
though I  have  seen  both  involved  at  the  same  time.  It  is 
generallj'  preceded  by  epiphora  or  water}^  eye,  and  it  will 
occasionally  follow  an  acute  attack  of  catarrhal  ophthal- 
mia, when  it  appears  as  if  the  conjunctival  inflammation 
had  spread  b}^  an  extension  along  the  caualiculi  to  the 
mucous  membrane  of  the  sac. 

The  symjjtoms  are  most  acute — pain,  heat,  redness,  and 
swelling  over  the  sac,  extending  to  both  the  upper  and 
lower  e^'elids,  which  ai'e  frequent!}^  so  edematous  as  to  be 
closed  over  the  eye.  The  pain  is  often  excessive ;  the 
slightest  pressure  with  the  finger  on  the  sac  being  almost 
intolerable.  These  s^'mptoms  continue  to  increase,  when 
suddenly  the  patient  experiences  a  sense  of  relief.  The  in- 
flamed sac  distended  with  pus  has  given  way,  and  the 
discharge  has  escaped  into  the  cellular  tissue  between  the 
skin  and  the  membranous  sac.  A  superficial  abscess  is 
now  formed,  and  the  pus  gradually  makes  its  way  to  the 
surface,  and  points  a  little  below  the  tendo  palpebrarum. 
If  the  disease  is  allowed  to  progress  untreated,  the  puru- 
lent contents  of  the  sac  are  discharged  through  the  iilce- 
rated  opening  on  the  face  ;  the  inflammation  subsides,  and 
the  parts  slowly  regain  their  normal  appearance  ;  but  fre- 
quently a  fistula  remains  in  the  site  of  the  wound  which 
communicates  directly'  with  the  sac,  and  through  which 
there  is  a  constant  flow  of  tears  on  to  the  cheek.     The 


FISTULA    OF    THE    LACHRYMAL    SAC.  333 

earl^'  s^-mptoms  of  acute  inflammation  of  tlie  sac  closely 
resemble  those  of  a  severe  attack  of  catarrhal  ophthalmia, 
as  the}^  are  often  associated  with  a  muco-puruleut  dis- 
charge from  the  e3-e  ;  but  in  all  cases  of  doubt  the  pressure 
of  the  finger  OA'er  the  lachrymal  sac  will,  by  the  pain  it 
l^i'oduces,  at  once  remove  all  obscurit^y. 

Treatment. — During  the  acute  stage  when  pus  is  form- 
ing, fomentations  of  hot  water,  or  of  decoction  of  poppy- 
heads,  should  be  frequently  used,  aud  in  the  intervals  a 
warm  linseed-meal  poultice  may  be  applied  over  the  part. 
As  soon  as  there  is  reason  to  believe  that  the  sac  is  dis- 
tended with  pus,  an  external  opening  is  to  be  made  to 
give  vent  to  it.  An  ordinarj'  cataract  knife  should  be 
made  to  enter  the  membranous  sac  a  little  below  the  tendo 
palpebrarum,  and  as  the  blade  is  withdrawn  the  incision 
should  be  carried  downwards  and  outwards  through  the 
skin  and  deep  tissues  to  the  extent  of  about  half  an  inch. 
A  small  strip  of  lint  is  then  to  be  placed  in  the  wound  to 
prevent  its  edges  uniting,  and  a  linseed-meal  poultice 
applied.  In  three  or  four  days'  time,  when  all  the  swell- 
ing has  subsided,  the  canaliculi  should  be  slit  up,  and  one 
of  Bowman's  probes,  or  the  narrow  end  of  Weber's  sound, 
be  passed  into  the  sac.  If  any  stricture  is  detected,  the 
probes  ought  to  be  passed  twice  a  week  for  a  short  time. 
If  after  a  fortnight  or  three  weeks  a  muco-purulent  dis- 
charge should  continue,  the  sac  must  be  washed  out  with 
an  astringent  lotion  (F.  38,  40,  47),  either  with  an  india- 
rubber  bottle  with  a  properl}'  constructed  tubular  nozzle, 
or,  what  is  far  better,  with  one  of  Wells's  lachrymal  sac 
syringes.  This  operation  should  be  repeated  twice  a 
week  until  all  discharge  ceases. 

Fistula  of  the  Lachrymal  Sac  is  one  of  the  results 
which  occasionally  follow  acute  inflammation  and  abscess 
of  the  sac.     A  small  sinuous  track  exists  between  the  sac 


334  DISEASES    OF    LACHRYMAL    APPARATUS. 

and  the  integument,  through  which  the  tears  ooze  on  to 
the  cheek.  I  have  also  seen  a  lachrymal  fistula  remain 
after  the  patient  has  given  up  the  wearing  of  the  old- 
fashioned  stAde,  which  was  introduced  by  an  opening 
made  in  the  sac  through  the  skin  just  below  the  tendo 
palpebrarum.  Lachrymal  fistula  is  occasionally  associ- 
ated with  necrosis  or  caries  of  the  bones  foi'ming  the 
lachrj^mal  canal. 

Treatment. — In  all  fistulre  connected  with  mucous  ca- 
nals, the  course  to  be  pursued  is,  first  to  cure  the  stric- 
ture and  restore  the  mucous  track  to  a  healthy  state, 
and  the  fistula  will  then  generall3'  close  of  itself.  This 
rule  holds  good  in  lachr3'mal  fistuloe,  and  for  this  purpose 
the  canaliculi  should  be  laid  open,  and  a  probe  passed 
into  the  sac  and  nasal  duct  to  ascertain  if  there  is  any 
stricture  or  disease  of  the  bonj^  walls. 

If  a  stricture  be  detected,  it  must  be  dilated  with 
probes,  or  with  Weber's  sound,  in  the  manner  already 
directed  in  page  329.  Should  there  be  a  chronic  thicken- 
ing of  the  mucous  membrane,  with  a  muco-purulent  dis- 
charge, the  sac  must  be  washed  out  twice  or  three  times 
a  week  with  an  astringent  lotion,  hy  means  of  an  india- 
rubber  bottle  or  Wells's  lachrymal  sj^ringe.  If  this  treat- 
ment fail,  the  fistula  should  be  laid  freel}'  open,  into  the 
sac,  with  a  cataract  knife,  the  point  of  which  is  to  be 
passed  through  the  fistulous  opening  on  the  face,  into 
the  membranous  portion  of  the  canal.  Into  the  wound, 
thus  made,  a  piece  of  lint  is  to  be  introduced,  but  it 
should  be  removed  in  twenty-four  hours,  after  which  the 
cut  edges  may  be  allowed  to  unite.  This  treatment,  com- 
bined with  the  use  of  probes  and  syringing  out  the  sac, 
seldom  fails  to  cure  the  fistula.  In  those  cases,  howevei', 
where  the  fistulous  opening  on  the  fiice  is  large,  as  when 
a  stj  le  has  been  long  worn  and  afterwards  abandoned,  it 


EPIPHORA.  335 

will  be  often  found  of  service  to  pare  the  edges  of  the 
opening,  and  unite  the  raw  surfaces  with  a  fine  suture. 

Epiphora  from  Mechanical  Obstruction  by  Tumors. 
— The  cavity  of  the  lachrymal  canal  may  be  partially  or 
completely  occluded  by  tumors,  which  either  take 
their  origin  from  within  the  sac,  or  from  those  ^^*^-  ^^• 
which  grow  from  the  antrum,  the  nostril,  or  from 
the  base  of  the  skull.     It  would  be  out  of  place 
here  to  discuss  the  nature  and  treatment  of  such 
growths;    they  will  be  found  fully  described  in 
works  on  general  surgery.     It  is  sufficient  to  in- 
dicate that  epiphora  may  be  caused  by  the  pres- 
ence of  tumors  either  within  or  in  the  neighbor- 
hood of  the  laclnymal  sac,  that  the  surgeon  may 
not  disregard  the  possibility  of  their  existence  in 
obstinate  cases  which  have  persistently  resisted  all 
treatment. 

To  SLIT  UP  THE  Canaliculus. — There  are  sev- 
eral ways  in  which  this  operation  may  be  per- 
formed. 

1.  The  canaliculus  may  be  laid  open  on  Crit- 
chett's  director  (Fig.  34).  The  patient  being- 
seated  in  a  chair,  the  operator  stnnds  behind  his 
head,  and  introduces  the  point  of  the  instrument, 
which  he  holds  between  his  finger  and  thumb, 
along  the  canaliculus,  and  then  drawing  the  lid 
outwards,  with  his  ring-finger,  to  render  the  parts- 
tense,  he,  with  the  other  hand,  slits  up  the  duct, 
b}'  passing  a  cataract  knife  along  the  groove  of  the 
director. 

Care  should  always  be  taken  to  keep  the  incis- 
ion external  to  the  caruncle,  as  if  the  edge  of  the 
knife,  as  it  is  run  along  the  director,  is  turned  too  much 


336  DISEASES    OF    LACHRYMAL    APPARATUS. 

towards  the  eye,  the  canalicuhis  will  ])e  divided  only  up 
to  the  canmcle,  beneath  which  the  remainder  of  the  duct 
will  tunnel,  unless,  indeed,  the  caruncle  be  divided,  which 
it  is  always  desirable  to  avoid. 

2.  The  canaliculus  ma}'  be  slit  up  by  Wecker's 
liG.  3o.  ]^iiife^  which  consists  of  a  fine  blade  of  the  shape 

and  size  represented  in  Fig.  35,  with  a  minute  but- 
ton at  its  extremity.  This  is  introduced  into  the 
punctum,  and  run  along  the  canal,  when,  b^'  slightly 
raising  the  hand,  and  giving  to  the  blade  a  cutting 
movement,  it  is  made  to  divide  the  canaliculus  to 
the  extent  required. 

3.  The  canaliculus  ma}'  be  laid  open  by  a  pair 
of  fine  scissors. 

Obliteration  op  the  Lachrymal  Sac  is  an 
operation  which  has  been  frequently  performed 
by  some  Continental  surgeons  of  eminence,  in 
cases  of  obstinate  chronic  inflammation,  which 
have  resisted  other  modes  of  treatment.  Various  means 
have  been  adopted  for  the  purpose  of  destrojing  the  mu- 
cous membrane  of  the  lachrymal  canal,  such  as  lajiug 
open  the  sac  by  a  free  external  incision,  and  apph'ing  to 
its  interior  either  the  actual  cautery-,  the  galvano-cautery, 
or  nitrate  of  silver,  potassa  c.  calce,  chloride  of  zinc,  or 
some  other  strong  caustic.  My  own  feeling  is  decidedlj^ 
averse  to  this  mode  of  treatment ;  the  few  patients  who 
have  come  under  my  notice,  after  having  been  submitted 
to  it,  have  stronglj'  prejudiced  me  against  the  operation. 
They  have  been  illustrations  of  the  difficult}',  well  known 
to  all  practical  surgeons,  of  destro3ing  a  mucous  canal. 
In  each  case  the  lachr3'mal  sac  was  not  obliterated,  but 
the  nasal  and  canalicular  openings  were  completely  closed, 
and  as  a  result  there  was  a  quantity  of  pent-up  secretion, 
which  distended  the  sac,  and  formed  a  globular  tumor 


REMOVAL    OF    LACHRYMAL    GLAND.  337 

below  tlie  tendo  palpebrarum.  There  are  few  cases  of 
chronic  lachr3'mal  disease  which  will  not  ultimately  yield 
to  well-directed  and  continuous  treatment. 

Removal  of  the  Lachrymal  Gland. — Mr.  Zachariah 
Laurence,  in  Xo.  12  of  the  "Ophthalmic  Review,"  advo- 
cates strongly  the  removal  of  the  lachrymal  gland  as  a 
radical  cure  for  lachrymal  disease.  He  states,  as  the  re- 
sult of  his  own  experience  of  this  treatment  in  abscess  of 
the  lachrymal  sac,  "that,  after  a  varying  time,  the  secre- 
tion of  pus  from  the  mucous  membrane  of  the  sac  de- 
creases and  finally  disappears."  After  discussing  fairly 
the  merits  of  this  operation,  and  the  mode  of  performing 
it,  he  cites  some  of  the  evil  consequences  which  may  fol- 
low. "In  most  cases,"  he  saj^s,  "slight  conjunctivitis 
ensues ;  this,  in  one  case,  ran  on  to  inflammation  of  some 
of  the  deeper  structures  ;  which,  however,  gradually  sub- 
sided under  appropriate  treatment,  without  inflicting 
any  permanent  injury  to  the  e3^e.  But  by  far  the  most 
serious  result  which  may  follow  the  operation,  is  ptosis 
of  the  upper  eyelid.  This  was,  in  almost  every  case  in 
which  I  observed  it,  of  purely  inflammatory  origin,  and 
graduallj'  subsided  spontaneouslj',  but  in  a  few  instances 
it  was  apparently  due  to  a  partial  division  of  the  levator 
palpebra?.'' 

When,  from  au}'  cause,  it  has  been  decided  to  excise 
the  lachrymal  gland,  the  operation  adopted  by  Mr.  Zach- 
ariah Laurence,*  may  be  performed.  An  incision  is  to 
be  made  immediately  below  the  upper  and  outer  third  of 
the  orbital  ridge,  through  the  skin  and  the  fascia  connect- 
ing the  periosteum  of  the  orbit  with  the  upper  edge  of 
the  tarsal  cartilage.  The  gland  is  then  to  be  carefully 
felt  for  with  the  finger,  and  having  made  out  the  exact 

*  Ophthalmic  Review,  No.  12,  p.  367. 
29 


338  DISEASES    OF    LACHRYMAL    APPARATUS. 

l)osition,  it  is  to  be  seized  with  a,  i)air  of  hooked  forceps, 
and  drawn  forwards  out  of  the  wound,  whilst  its  celhilar 
connections  are  carefully  severed  with  the  knife.  Free 
hemorrhage  often  accompanies  the  operation,  but  the 
bleeding  may  generally  be  arrested  by  a  stream  of  cold 
water  from  a  sponge.  The  wound  should  not  be  finally 
closed  until  all  bleeding  has  ceased. 

Diseases  of  the  Lachrymal  Gland  are  extremely 
rare;  so  seldom,  indeed,  is  the  gland  affected,  that  in  the 
Reports  of  the  Royal  London  Ophthalmic  Hospital  for 
ten  3'ears,  from  185t  to  1801  inclusive,  out  of  a  yearly 
average  of  over  12,000  new  cases,  only  twenty  of  "dis- 
eased lachrymal  gland "  are  recorded.  No  doubt  the 
lachrymal  gland  is  often  secondai'ily  involved  in  malig- 
nant tumors  of  the  orbit,  but  this  is  apt  to  be  overlooked, 
from  the  fact  that  the  gland  is  either  excised,  unnoticed, 
with  the  morbid  growth,  or  else  it  is  sloughed  out  by  the 
action  of  the  caustics,  which  are  afterwards  used  to  de- 
stroy any  portions  of  the  tumor  which  may  have  been  left 
behind.  Although  the  lachrymal,  like  all  conglomerate 
glands,  enjo3-s  a  special  immunity  from  disease,  yet  it  is 
not  altogether  exempt,  and  to  those  affections  to  which 
it  may  be  subjected,  I  shall  now  refer. 

Inflammation  of  the  Lachrymal  Gland — Dacnjo- 
adenitis — may  be  either  chronic  or  acute ;  generally-,  liow- 
ever,  it  is  the  former.  It  may  occur  without  any  appar- 
ent cause,  or  it  may  arise  from  injury. 

Symptoms. — When  chronic^  thei'e  is  tenderness  and  en- 
largement of  the  gland,  which  can  be  felt  by  the  finger, 
beneath  the  outer  part  of  the  edge  of  the  roof  of  the  orbit. 
There  will  be  probably  also  some  oedema  of  the  oculo-pal- 
pebral  fold  of  conjunctiva,  and  redness  of  the  lid.  If 
there  is  much  swelling  of  the  gland,  the  e^-e  will  be  dis- 
placed dowuwai'ds  and  inwards. 


CYSTS  OF  THE  LACHRYMAL  GLAND.       339 

If  the  inflammation  is  acute ^  there  will  be  more  pain, 
redness,  and  swelling  in  the  region  of  the  gland,  with 
(L'dema  of  the  lid,  and  chemosis  of  the  conjunctiva.  These 
symptoms  may  subside  under  treatment,  or  they  may  go 
on  to  the  formation  of  pus. 

Treatment. — For  the  chronic  inflammation  of  the  gland 
small  doses  of  the  iodide  of  potassium  (F.  74),  or  of  the 
iodide  of  ammonium,  ma}'^  be  given,  and  an  ointment  of 
ammonii  iodid.  gr.  30,  adipis  gi'.  240,  may  be  gently 
rubbed,  night  and  morning,  over  the  swelling.  For  the 
acute  symptoms,  one  or  two  leeches  may  be  applied  to 
the  temple,  and  a  warm  linseed-meal  poultice  over  the 
eye.  If  the  inflammation  should  continue,  and  pus  form, 
an  incision  should  be  made  in  the  line  of  the  orbit  to  give 
vent  to  it,  as  soon  as  there  is  sufficient  evidence  of  its 
presence. 

Cysts  of  the  Lachrymal  Gland  —  Bacryops  —  may 
arise  from  acute  inflammation  and  abscess,  or  from  injury. 
Their  formation  is  apparently  caused  b3'  an  obstruction, 
more  or  less  complete,  of  one  of  the  excretory  ducts,  in 
which  the  secretion  of  the  gland  accumulates;  the  walls 
of  the  canal  become  distended,  and  a  small  elastic  tumor 
shows  itself  in  the  localit^'^  of  the  lachrj-mal  gland,  over 
which  the  skin  is  freely  movable.  In  a  paper  by  Mr. 
Hulke  on  this  subject,  in  vol.  i  of  the  "  Ophthalmic  Hos- 
pital Reports,"  he  sa3's :  "  The  most  characteristic  and 
striking  sign  of  dacryops  is  the  sudden  enlargement 
which  the  tumor  undergoes  when  the  patient  cries."  If 
the  cyst  attains  a  large  size  it  may  seriously  interfere 
with  the  movements  of  the  eyelid. 

Treatment. — The  most  efficient  method  of  dealing  with 
these  cysts  is  b}^  the  establishment  of  a  permanent  ttstula 
on  its  inner  or  conjunctival  surface,  by  which  the  tears 
may  constantly  drain  away.    For  the  mode  of  accomplish- 


840  DISEASES    OF    LACHRYMAL    APPAllATUS. 

ing  this,  sec  Treatment  of  Fistula  of  Lachrymal 
Gland,  in  the  next  section..  An  attempt  to  dissect  the 
cyst  out  through  an  incision  of  the  skin  is  apt  to  lead  to 
the  formation  of  a  permanent  external  fistula. 

FiSTLLA  OF  THE  LACHRYMAL  GlxVND  —  Dacryops  Jistu- 
losus  —  may  be  the  result  of  an  abscess  of  the  lachrymal 
gla»d  which  has  burst  externally ;  or  of  a  cj'st  of  the 
gland  or  of  an  incised  wound.  There  is  a  minute  opening 
in  the  upper  and  outer  surface  of  the  lid,  through  which 
the  tears  from  time  to  time  trickle. 

Treatment. — The  edges  of  the  fistulous  opening  ma}'^ 
be  pared  with  a  fine  scalpel,  and  be  then  brought  together 
with  a  single  wire  suture ;  or  the  eud  of  a  fine-pointed 
cauter}',  having  been  made  hot,  ma}-  be  introduced  into 
the  fistulous  orifice ;  or  the  galvano-caustic  apparatus 
may  be  used  in  a  similar  manner.  The  plan  of  treatment, 
however,  which  was  adopted  bj'  Mr.  Bowman,  in  a  case 
recorded  by  Mr.  Hulke,  *  was  so  successful  that  I  will 
quote  it  in  detail.  "  A  single  thread  of  silk  was  armed 
with  a  needle  at  each  end,  and  one  of  the  needles  was 
introduced  into  the  fistulous  orifice  in  the  skin  on  the 
outer  surface  of  the  ej-elid,  and  carried  for  a  short  dis- 
tance upwards;  it  was  then  made  to  pierce  the  fibro-car- 
tilage  of  the  lid  and  the  conjunctiva,  and  the  thread  was 
drawn  out  at  the  inner  surface  of  the  lid.  A  similar 
manoeuvre  was  repeated  with  the  other  needle,  and  the 
thread  was  drawn  out  at  the  inner  surface  of  the  lid,  at 
the  distance  of  a  qxiarter  of  an  inch  from  the  first,  and  a 
little  nearer  the  attached  border  of  the  lid.  Li  this 
wa}-  the  C3'st  was  pierced  at  two  points  by  the  thread, 
which  encircled  in  a  loop  the  small  intervening  })ortion  of 
tissue.     The  two  ends  of  the  thread  were  then  brought 

*  Kuyal  London  Ophthahiiic  Hospital  Kuports,  vol.  i,  p.  288. 


IIYI'EIITIIOI'IIY    OF    LACHRYMAL    GLAND.  341 

out  a,t  the  outer  commissure,  and  secured  upon  the  tem- 
ple with  a  piece  of  sticking-plaster.  The  presence  of  the 
thread  occasioned  very  slight  annoj^ance  ;  the  conjunc- 
tiva lining  the  upper  ej'clid  became  a  little  swollen  and 
injected  ;  and  tears  continued  to  flow  from  the  orifice  in 
the  skin,  but  less  abundantly.  Ten  days  afterwards,  the 
thread  was  replaced  by  a  thicker  one,  which  produced 
more  irritation,  and  the  conjunctiva  immediately  around 
it  became  slightly  granular.  An  attempt  was  now  made 
to  close  the  aperture  in  the  skin.  It  was  drawn  out  with 
a  forceps  and  cut  off  with  scissors,  together  with  the  little 
l)iece  of  skin  immediately  around  it.  The  edges  of  the 
wound  were  brought  together  with  two  serres  fines,  which 
were  replaced,  in  the  evening  of  the  same  day,  by  slips  of 
plaster.  When  she  was  next  seen,  after  an  interval  of 
four  days,  the  wound  had  quite  healed,  and  the  fistula  in 
the  cutaneous  surface  of  the  lid  had  perfectly  closed." 
In  another  week  the  thread  was  withdrawn,  and  the  small 
bridge  of  tissue  which  had  been  encircled  by  the  loop, 
cut  out.  "  This  opening  in  the  conjunctiA'a  continned 
patent,  and  there  was  no  further  collection  of  mucus  nor 
tears  in  the  cj'st." 

Simple  Hypertrophy  or  Chronic  Enlargement  of 
THE  Lachry'mal  Gland  is  occasionally  met  with.  The 
enlarged  gland  forms  an  unsightly  prominence  in  the 
upper  and  outer  part  of  the  orbit. 

Treatment. — The  iniguent.  ammonii  iodid.  gr.  30  ad 
adipis  gr.  240,  may  be  rubbed  into  the  swelling  night  and 
morning,  and  small  doses  of  the  potass,  iodid.,  or  of  the 
syrup,  ferri  iodid.,  may  be  given  twice  a  da}'.  Should 
this  treatment  have  no  effect,  the  unsightly  prominence 
may  be  excised,  or  the  whole  gland  may  be  removed. 
In  a  case  lately  under  the  care  of  my  colleague,  Mr. 

29* 


342  DISEASES    OP   TUB    EYELIDS. 

Streatfeild,  he  removed  the  protnuliiig  portion  and  left 
the  remainder  of  the  gland.  The  patient  made  a  satis- 
factory^ recovery,  and  has  since  continued  ■well. 


CHAPTER  X. 


DISEASES    OF    THE    EYELIDS. 


Tinea  Tarsi  is  a  disease  of  the  follicles  of  the  eye- 
lashes.  It  is  chronic  in  its  progress,  difficult  to  com- 
pletel}^  subdue,  and  very  recurrent.  In  the  early  stage, 
the  margins  of  the  lid  are  red  and  irritable ;  there  is  at 
first  an  excessive  secretion  from  the  follicles  of  the  cilia, 
which  accumulates  during  the  night,  and  causes  the  lids 
to  be  gummed  together  in  the  morning.  As  the  disease 
advances,  the  discharge  becomes  purulent  and  cakes  into 
scabs,  which  adhere  to  the  margins  of  the  lids  and  to  the 
lashes.  Small  pustules  then  form  at  the  roots  of  the 
lashes,  and  these  burst  and  leave  superficial  ulcerations, 
which  are  generalh'  covered  with  yellow  crusts.  The  eje- 
lashes  gradually  fall  out,  and  the  edges  of  the  lid  lose 
their  sharp  outline,  and  become  rounded,  thickened,  and 
everted.  With  the  eversion  of  the  tarsal  borders,  the 
punctum  lachrymale  is  drawn  away  from  the  globe,  and 
there  is  a  slight  but  constrmt  overflow  of  tears,  which  ex- 
coriates the  lids  and  keeps  up  the  redness  and  irritation. 
To  this,  the  extreme  stage  of  tinea  tarsi,  the  term  lipjn- 
hido  has  been  applied. 

Tinea  tarsi  is  very  common  amongst  all  classes,  but 
especially  amongst  the  poor.  It  is  frequently  associated 
with  debility  and  constitutional  derangement,  and  is  one 
of  tlie  sequences  of  scarlatina,  lueasles,  and  whooping- 


TINEA    TARSI.  343 

conoli.  Patients  who  have  once  suffered  from  it  arc  very 
apt  to  haA'e  recurrences  when  from  any  cause  their  health 
fails. 

Treaimenf. — One  of  the  most  important  elements  in 
the  treatment  of  tinea  tarsi  is  strict  cleanliness.  The  lids 
should  be  bathed  with  warm  or  tepid  water  night  and 
morning,  and  all  scabs  of  dried  secretion  be  removed  be- 
fore the  application  of  any  of  the  remedial  agents.  On 
going  to  bed,  a  little  of  the  unguent,  h^-drarg.  nitratis 
dilut.  (F.  102),  or  of  the  unguent,  hydrarg.  nitric-oxj'd. 
dilut.  (F.  103),  should  be  smeared  on  the  tarsal  edges; 
and  in  tlie  morning,  after  the  lids  have  been  thoroughly 
cleansed  from  all  the  discharge  which  has  accumulated  on 
them  during  the  night,  they  should  be  bathed  with  a  mild 
astringent  lotion  (F.  39,  40).  The  lotion  may  be  also 
used  several  times  during  the  day.  In  children,  when  the 
63'elashes  are  very  long,  it  is  often  of  service  to  cv;t  them 
off'  close  to  the  lids  with  a  pair  of  scissors,  as  the  lids  are 
more  easily  kept  clean  when  there  are  no  lashes  upon 
which  the  discharge  can  cake.  This  plan  of  treatment  is 
usually  sufficient  to  cure  a  slight  case  of  tinea;  but  where 
there  are  superficial  ulcerations  or  pustules  at  the  roots 
of  the  cilia,  other  means  must  be  adopted.  Each  morning 
after  the  lids  have  been  freed  from  all  discharge,  a  solu- 
tion of  nitrate  of  silver,  gr.  5  to  gr.  10  ad  aquje  s  1,  should 
be  applied  with  a  camel's-hair  brush  to  the  pustules  or 
ulcerated  spaces  between  the  lashes ;  or  they  may  be 
touched  twice  or  three  times  a  week  with  a  stronger  solu- 
tion of  nitrate  of  silver,  or  with  the  diluted  nitrate  of 
silver  points  (F.  5).  In  the  worst  cases,  where  the  edges 
of  the  lids  are  rounded,  thickened,  and  excoriated,  Avith 
the  puncta  drawn  away  from  the  globe,  the  canaliculi 
should  be  laid  open  in  the  manner  directed  at  page  335, 
so  as  to  form  conduits  along  Avhich  the  tears  may  flow 
into  the  sac ;    and  a  weak  solution  of  nitrate  of  silver 


344  DISEASES    OF    THE    EYELIDS. 

should  be  painted  daily  on  the  red  excoriated  margins. 
Where  there  is  great  irritabilit}-  and  excoriation  of  the 
tarsal  edges,  I  have  found  much  benefit  from  the  use  of 
the  lotio  boracis  (F.  48).  Whilst  ordering  local  applica- 
tions to  the  lids,  attention  must  also  be  paid  to  the  state 
of  the  patient's  health.  Tonics  of  irou  and  quinine  usu- 
ally do  good,  but  in  very  chronic  cases,  accompanied  with 
a  thickened  and  eczeniatous  state  of  the  lids,  small  doses 
of  the  liquor  arsenicalis  given  twice  or  three  times  a  day 
will  be  often  of  service.  It  is,  however,  a  medicine  which 
should  be  seldom  prescribed  for  jouug  children. 

Hordeolum — i<tije — is  a  small  boil  on  or  near  the  mar- 
gin of  the  lid.  It  is  closely  connected  with  one  or  more 
of  the  cilia,  and  in  some  cases  it  seems  as  if  the  stye  was 
simply  a  suppurating  hair-follicle.  Generally  only  one 
stye  appears  at  a  time  on  the  lid,  but  others  are  ver^^  apt 
to  follow.  A  succession  of  them  is  indicative  of  an  ener- 
vated state  of  health. 

Treatment. — In  the  veiy  early  stage,  when  the  patient 
feels  that  a  stye  is  coming,  and  before  suj^puration  has 
commenced,  1  have  thought  that  I  have  on  several  occa- 
sions succeeded  in  arresting  its  progress  by  drawing  once 
across  the  tender  spot  on  the  tarsal  edge,  a  point  of  the 
mitigated  nitrate  of  silver  (F.  5),  or  a  camel's-hair  pencil 
charged  with  nitrate  of  silver,  as  directed  at  page  66.  It 
is  a  remedy  worth  trying,  as  if  it  fails,  the  patient  has  in 
no  way  suffered.  During  the  advance  of  the  stye,  warm 
applications  are  best ;  fomentations  with  hot  water,  or  the 
decoction  of  poppy-heads,  and  a  warm  poultice  at  night, 
covered  with  a  piece  of  oiled  silk.  It  is  seldom  necessary 
to  puncture  a  stye ;  the  pus  will  select  its  own  site  at  which 
to  point  and  make  an  exit  for  itself.  The  bowels  should 
be  cleared  of  all  irritating  matter  by  a  purgative,  and 
some  tonic  prescribed;  usually  the  mineral  acids  „with 


ECZEMA    OF    THE    EYELIDS — TRICHIASIS.  345 

bark  (F,  fil),  or  quinine  with  tbe  perchloride  of  iron  (F. 
66),  agree  ver^'  well.  In  children  the  i)ulv.  cinchonas  cum 
soda  (F.  118),  or  mist,  cinchonie  (F.  110,  111),  or  some 
preparation  of  iron  (F.  116,  11 T)  ma}' be  ordered.  When 
all  suppuration  has  ceased,  the  lids  ma}'  be  bathed  with 
a  slighth'  stimulating  lotion  (F.  40),  and  at  bedtime  a 
little  of  the  unguent,  hydrarg.  nitratis  dilut.  (F.  102)  may 
be  smeared  on  the  tarsal  edges. 

Eczema  of  the  Eyelids  frequently  accompanies  stru- 
mous corneitis  and  phlyctenular  ophthalmia  in  children. 
It  is  often  associated  with  eczema  behind  the  ear  and 
sores  about  the  nostrils. 

Treatment. — If  the  child  is  seen  at  the  commencement 
of  the  disease,  when  the  eczematous  s^'mptoms  are  acute, 
the  bowels  should  be  well  acted  on  with  a  powder  (F. 
124,  128);  and  a  mixture  should  be  given  repeatedly 
during  the  da}',  with  small  doses  of  tartarated  anthnony 
(F.  108).  The  diet  should  be  strictly  regulated.  The  best 
local  application  will  probably  be  the  lotio  boracis  (F. 
48);  but  if  this  should  fail,  a  lotion  with  zinci  oxyd.  (F. 
43)  may  be  tried.  Ointments  generally  irritate,  and  in 
most  cases  should  be  avoided.  After  three  or  four  days 
the  antimonial  mixture  should  be  omitted,  and  a  prepa- 
ration of  iron  or  bark  be  ordered  (F.  116',  110). 

Trichiasis,  is  an  irregular  displacement  of  the  eye- 
lashes, some  of  which  are  inverted  and  often  stunted  in 
their  growth.  By  their  friction  against  the  globe  they 
cause  severe  irritation ;  and  when  the  inverted  cilia  brush 
against  the  cornea,  they  render  it  nebulous  and  vascular. 
Trichiasis  may  be  partial,  that  is,  limited  to  a  few  lashes, 
or  it  may  aftect  the  whole  row.  For  the  causes  and  treat- 
ment of  trichiasis,  see  the  next  section. 


?A(')  DISEASES    OF    THE    EYELIDS. 

DiSTiciiiASis  is  when  from  some  cause  the  hulbs  of  the 
cilia  have  been  so  shifted  that  there  is  a  distinct  doul)le 
row  of  lashes.  The  inner  row  is  usually  turned  inwards, 
and  sometimes  so  completely  that  the  lashes  cannot  be 
seen  without  slightly  everting  the  lid  with  the  finger. 
Distichiasis  maj'  be  partial,  or  it  may  involve  the  whole 
of  the  cilia. 

The  causes  of  both  trichiasis  and  distichiasis  are  puru- 
lent and  granular  ophthalmia.  The  contraction  of  the 
palpebral  conjunctiva,  which  takes  place  during  the  heal- 
ing of  the  granulations,  pulls  upon  the  margins  of  the 
lid,  and  causes  a  displacement  of  the  bulbs  of  the  cilia, 
and  an  incurvation  of  the  tarsal  cartilage. 

Treatment. — The  best  operation  for  severe  cases  of  tri- 
chiasis or  distichiasis,  is  excision  of  the  whole  row  of  the 
cilia.  The  patient  is  thus  rapidly  and  permanently  re- 
lieved from  a  long-felt  trouble,  and  the  disfigurement  is 
very  slight.     It  is  not  to  be  compared  Avith  the  unsightli- 

FiG.  36. 


ness  produced  by  a  loss  of  the  oculo-palpebral  fold  of 
skin,  which  is  the  usual  result  of  those  operations  which 
endeavor  to  rectify  the  displaced  lashes  b}^  ^ortening  the 
integument  of  the  upper  lid.  It  is  seldom  necessar}^  to 
excise  the  cilia  of  the  lotver  lid,  as  the  removal  of  a  fold 
of  skin,  with  the  corresponding  portion  of  the  orbicularis, 
will  usually  suffice.  (See  page  349.)  In  slight  cases,  where 
oidy  a  few  of  the  cilia  are  affected,  the  distorted  or  dis- 
l)laced  lashes  may  be  pulled  out  with  a  pair  of  cilia  for- 
ceps (Fig.  30),  or  they  may  be  excised.  If  the  inverted 
lashes  involve  as  much  as  half  the  tarsal  margin,  it  is 


OPERATION  FOR  REMOVAL  OF  EYELASHES.    847 

better  to  excise  the  entire  row,  as  it  is  less  noticeable  than 
when  half  the  length  of  the  cilia  have  been  removed. 

Operation  for  the  Removal  op  the  Eyelashes. — 
This  consists  in  first  splitting  the  border  of  the  tarsal 
cartilage,  and  then  excising  the  thin  wedge  of  it  in  which 
the  bulbs  of  the  lashes  are  imbedded. 

The  lid  being  drawn  tense  by  one  hand  of  the  operator, 
with  the  other  he  makes  a  long  incision  with  a  cataract 
knife  along  the  inner  or  ocular  edge  of  the  lashes,  and  of 
a  sufficient  depth  for  the  point  of  the  knife  to  pass  be- 
3'oud  their  roots.  A  second  incision  is  now  to  be  made 
on  the  outer  surface  of  the  lid  just  behind,  but  parallel  to 
the  row  of  lashes,  so  as  to  cut  through  the  integuments 
and  the  margin  of  the  cartilage  just  above  the  bulbs  of 
the  cilia ;  the  depths  of  the  two  incisions  will  thus  meet, 
and  the  whole  row  of  lashes  will  be  excised.  The  cut 
surface  of  the  cartilage  should  now  be  carefully  scanned 
over,  so  that  if  any  of  the  bulbs  of  the  lashes  have  es- 
caped excision  they  may  be  removed ;  should  any  be 
left,  new  lashes  will  sprout  again  from  them,  and  the  ob- 
ject of  the  operation  will  not  be  completely  fulfilled,  as 
even  a  single  eyelash  brushing  against  the  cornea  will 
cause  considerable  irritation.  The  bulbs  of  the  lashes 
may  be  recognized  by  their  appearing  as  fine  black  dots. 

Lastly,  the  skin  should  be  gently  pressed  over  the  cut 
edge  of  the  cartilage,  and  a  compress  of  wet  lint  be  ap- 
plied to  the  eye  with  a  bandage.  No  sutures  should  be 
used. 

By  this  operation  the  lid  is  not  shortened,  for  the  edge 
of  the  cartilage  is  simply  split,  and  the  thin  wedge  of  it 
removed  in  which  the  lashes  are  implanted. 

To  facilitate  the  performance  of  this  operation,  either 
Snellen's  eyelid  forceps  or  the  horn  spatula  ma}',  when 
practicable,  be  used.     If  Snellen's  forceps  are  selected. 


348  DISEASES    OF   THE    EYELIDS. 

the  lower  blade  should  be  gently  insinuated  beneath  the 
upper  eyelid  as  far  as  it  will  pass,  and  then,  with  a  few 
turns  of  the  screw,  a  metallic  clamp  is  made  to  compress 
firmly  the  circumference  of  the  lid,  with  the  exception  of 
its  tarsal  border,  which  is  left  free  for  tlie  operator. 

Various  means  have  been  tried  for  the  destruction  of 
the  hair  follicles  by  caustics,  but  the  treatment  is  only 
applicable  to  those  cases  where  the  displacement  of  the 
lashes  is  limited,  and  even  then  it  is  not  very  satisfactor3^ 

Pr.  Herzenstein*  has  recommended  the  use  of  a  seton 
for  the  destruction  of  the  bulbs  of  the  cilia,  and  in  cases 
of  partial  trichiasis  it  seems  applicable.  One  end  of  the 
thread  is  first  introduced  by  a  fine  needle  through  the 
edge  of  the  tarsal  cartilage,  and,  passing  it  upwards  sub- 
cutaneously,  it  is  brought  out  at  a  point  beyond  the  roots 
of  the  cilia,  and  again  introduced  through  the  same  open- 
ing, it  is  carried  onwards  beneath  the  skin  around  the 
bulbs  of  the  lashes  to  be  destroj^ed,  until  finally  it  emerges 
on  the  edge  of  the  lid  in  a  line  with  the  spot  at  which  it 
first  entered.  The  two  ends  of  the  thread  are  now  tied 
together,  and  they  are  allowed  to  remain  until  they  cut 
their  way  out,  by  which  time  the  hair  bulbs  are  destroyed 
by  suppuration. 

Entropion,  or  an  Inversion  of  the  Edge  op  the 
Eyelids. — There  are  two  forms  of  this  disease. 

a.  The  spasmodic  entropion. 

[i.  The  chronic  entropion,  which  is  dependent  on  struc- 
tural changes  of  the  conjunctiva  of  the  lid. 

a.  The  spasmodic  entropion  is  due  to  a  spasmodic  con- 
traction of  the  orbicularis.  It  may  occur  after  an  injur3', 
or  during  any  affection  of  the  eye,  which  is  accompanied 

*  Archiv  fiir  Ophtliahnologie,  bd.  xii,  ji.  76,  1866. 


ENTROPION.  349 

by  luucli  pliotopliol»iaand  lachrymation,  and  particularly 
if  the  eye  has  been  for  some  time  closely  bandaged  up. 

From  the  constant  overflow  of  tears,  the  tarsal  border 
becomes  red  and  excoriated;  and,  from  the  repeated 
spasmodic  contractions  of  the  orbicularis  muscle,  the 
edge  of  the  lid  becomes  curled  inwards — sometimes  to 
such  an  extent  that  the  eyelashes  cannot  be  seen  without 
first  everting  the  tarsal  margin  by  drawing  it  down  with 
the  finger.  Spasmodic  entropion  is  frequently  seen  after 
the  operation  for  cataract,  and  especialh'  iu  old  people, 
with  the  skin  of  the  lids  loose  and  wrinkled.  This  inver- 
sion of  the  lashes  is  usually  confined  to  the  lower  lid. 

For  the  treatment  of  this  form  of  entropion,  it  is  suflBi- 
cient  to  remove  a  nari'ow  strip  of  the  skin  and  of  the  or- 
bicularis muscle,  close  up  to  and  nearly  the  length  of  the 
margin  of  the  lid.  This  is  to  be  done  by  first  pinching 
up  a  fold  of  the  skin  in  a  line  with  the  lid  by  a  pair  of 
forceps,  and  cutting  it  off"  with  a  pair  of  scissors.  A  cor- 
responding piece  of  the  orbicularis  is  then  to  be  seized 
with  the  forceps  and  excised  in  a  similar  manner.  No 
sutures  will  be  required,  but,  when  all  the  bleeding  has 
ceased,  the  edges  of  the  wound  should  be  gently  pressed 
together,'  and  a  light  pad  of  wet  lint  with  a  bandage 
fastened  oA-er  them.  Complete  union  will  be  elTected  in 
two  or  three  days. 

/?.  CJu-onic  entropion  is  caused  by  purulent  and  gran- 
ular ophthalmia ;  by  injuries  of  the  conjunctiva  of  the  lids 
from  hot  metal,  lime,  mortar,  or  any  other  escharotic 
which  may  have  caused  a  destruction  of  a  portion  of  that 
membrane.  As  cicatrization  proceeds,  the  contraction  of 
the  conjunctiva  causes  the  margin  of  the  lid  with  its  lashes 
to  become  inverted  and  drawn  towards  the  globe.  This 
folding  in  of  the  lashes  is  a  source  not  only  of  great  dis- 
comfort to  the  patient,  but  of  danger  to  the  eye.  The 
continued  brushing  of  the  lashes  against  the  cornea  \r\ 

30 


350  DISEASES    OF    THE    EYELIDS. 

every  movement  of  the  eye  is  apt  to  induce  a  trouljlesomc 
form  of  eorneitis  with  ulceration,  and  will  invariably  after 
a  time  render  the  cornea  nebulous  and  vascular. 

Treatment. — When  the  entropion  is  severe,  and  depen- 
dent on  a  thickened  and  contracted  paljiebral  conjunctiva, 
produced  hy  granular  ophthalmia ;  or  on  cicatrization 
following  an  injury  to  that  membrane  from  some  escba- 
rotic,  the  onl}'  operation  which  will  afford  permanent  re- 
lief is  the  removal  of  the  entire  row  of  lashes.  (See  page 
347.)  Associated  with  the  inversion,  there  is  frequently 
a  considerable  contraction  of  the  palpebral  aperture. 
"When  this  exists  the  external  canthus  should  be  first  di- 
vided with  a  pair  of  scissors,  and  then  a  fine  suture  in- 
serted between  the  divided  conjunctiva  and  the  opposite 
point  of  skin,  in  order  to  prevent  the  reunion  of  the  edges 
of  the  incision.  There  are,  howcA'er,  many  cases  of  en- 
tropion due  parti}"  to  spasm  of  the  orbicularis,  and  partly 
to  a  contraction  of  the  palpebral  conjunctiva.  For  this 
class,  one  or  other  of  the  numerous  operations  for  evert- 
ing the  infolded  tarsal  cartilage,  and  rectifying  the  dis- 
placed lashes,  may  be  performed. 

Mr.  Streatfeild  recommends  the  following  operation  of 
"  grooving  the  fibro-cartilage,"  a  full  account  of  which  is 
given  in  vol.  i  of  The  Ophthalmuic  Hospital  Reports,  p. 
1-25.  "The  lid  is  held  with  Desmarres'  forceps,  the  fiat 
blade  passed  under  the  lid,  and  the  ring  fixed  upon  the 
skin,  so  as  to  make  it  tense  and  expose  the  edge  of  the 
lid.  An  incision,  with  a  scali)el,  is  made  of  the  desired 
length,  just  through  the  skin,  along  the  palpebral  margin, 
at  a  distance  of  a  line  or  less,  so  as  to  expose  but  not  to 
divide  the  roots  of  the  lashes  ;  and  then  just  be^'ond  them 
the  incision  is  coittinued  down  to  the  cartilage  (the  ex- 
tremities of  this  wound  are  inclined  towards  the  edge  of 
the  lid)  :  a  second  incision,  farther  from  the  palpelnal 
margin,  is  made  at  once  down  to  the  cartilage,  in  a  similar 


ECTROPION.  351 

direction  to  the  first,  and  at  a  distance  of  a  line  or  more, 
and  joining  it  at  both  extremities  ;  these  two  incisions  are 
tlien  continued  deeph'  into  the  cartilage  in  an  oblique 
direction  towards  each  other.  Vi'ith  a  pair  of  forceps  the 
strip  to  be  excised  is  seized  and  detached  with  the  scalpel." 

Another  excellent  operation  is  one  practised  by  Arlt. 
He  first  splits  the  tarsal  cartilage  and  severs  the  entire  row 
of  cilia  from  the  snlyacent  parts  as  in  the  operation  for 
excision  of  the  lashes,  page  347,  but  with  this  difference, 
that  he  leaves  them  still  attached  at  each  extremity  to  the 
lid.  He  then  removes  a  fold  of  skin  the  length  of  the  lid 
and  adjoining  the  incision  already  made,  and  into  the  raAv 
surface  thus  exposed  he  plants  the  row  of  cilia,  leaving 
the  skin  connection  at  either  end  to  maintain  their  vitality 
until  union  is  effected.  A  few  fine  sutures  are  inserted  to 
keep  the  parts  in  situ. 

Graefe,  Pagenstecher,  and  Snellen  have  suggested  dif- 
ferent operations  for  the  relief  of  entropion.  A  detailed 
account  of  each  will  be  found  in  some  of  the  copious 
treatises  on  the  Eye  which  have  been  latel}-  published. 

Ectropion,  or  Eversion  of  the  Eyelids,  may  be  in- 
duced b}'  either  injury  or  disease.  The  worst  and  most 
intractable  cases  are  those  which  are  the  result  of  injury 
either  to  the  e^yelid,  or  to  the  tissues  in  its  immediate 
vicinity.  When  the  ectropion  is  caused  by  disease,  the 
lower  lid  is  the  one  most  frequently  everted ;  but  when  it 
is  the  result  of  accident,  the  upper  lid  suffers  equally  with 
its  fellow.  The  deformity  which  ectropion  produces  is 
often  very  great,  and  the  cause  of  much  annoyance,  if  not 
of  actual  suffering.  In  all  except  very  slight  cases,  the 
eye  having  lost  a  part  of  its  natural  protection,  is  liable, 
from  undue  exposure,  to  attacks  of  recurrent  inflamma- 
tion of  its  conjunctival  surface.  It  also  becomes  what  is 
commonly  called  a  watery  eye:  owing  to  the  eversion  of 
the  eyelid  the  [)unc'lum  is  drawn  away  from  the  globe,  and 


352  DISEASES  OF  THE  EYELIDS. 

some  of  the  tears  are  constantly  flowino- over  tlic  lid  f)n  to 
the  cheek.  Lastly,  after  the  lid  has  been  long  everted,  the 
conjunctiva  is  ver}'  apt  to  become  changed  in  appearance 
and  character.  In  some  instances  it  gi'ows  almost  cutic- 
vilar;  whilst  in  others  it  becomes  so  hyi)ertrophied  and 
granular  as  to  acquire  somewhat  the  look  of  a  fungoid  ex- 
crescence. 

Ectropion  may  be  produced  — 

a.  By  the  cicatrization  following  the  destruction  of  a 
part  or  the  whole  of  the  skin  of  the  e^'elid. 

/5.  By  the  cicatrization  of  a  wound  in  the  neighborhood 
of  the  eyelids. 

y.  By  abscesses  in  the  cellular  tissue  at  any  point  near 
the  margin  of  the  orbit,  and  especial!}-  if  associated  with 
diseased  bone. 

In  the  cicatrization  which  follows  an  absolute  destruc- 
tion of  a  portion  of  the  integument,  the  loss  is  not  re- 
placed b}'  a  regrowth,  but  the  breach  is  chiefl}'  repaired 
hj  a  drawing  together  of  the  surrounding  parts,  borrow- 
insT  as  it  were  from  the  abundance  of  skin  in  the  neigh- 
borhood  to  close  the  gap  which  has  been  occasioned  by 
the  injur3\  The  wound  is  thus  greatly  reduced  in  size, 
and  that  which  j^et  remains  open  is  repaired  by  the  de- 
velopment of  a  cicatricial  tissue,  which  closely  resembles 
the  true  skin,  but  differs  from  it  in  its  want  of  elasticitv, 
softness,  and  vitality. 

If  the  wound  is  in  the  vicinity  of  the  orbit,  the  con- 
traction which  accompanies  the  healing  process  draws 
upon  the  tarsal  edge  of  the  lid,  and  gradually  everts  it. 
This  contraction  of  the  neighboring  skin  towards  the 
seat  of  the  injur}-  is  not  confined  to  the  actual  period  of 
cicatrization,  but  continues  for  many  months  afterwards, 
increasing  the  extent  of  the  ectropion,  whilst  it  diminishes 
the  size  of  the  cicatrix. 

When  the  ectropion  is  caused  by  an  abscess  near  the 


EOTUOl'ION.  353 

iiiargiii  ol"  the  orbit,  very  little  if  any  of  the  skin  may 
have  been  involved  in  the  suppuration.  The  ectropion  is 
then  dependent  on  a  portion  of  the  cellular  tissue  having 
been  destroyed  by  sloughing,  and  the  skin  becoming 
drawn  and  adherent  to  the  parts  beneath,  instead  of 
gliding  smoothly  over  them.  With  the  contraction  of  the 
skin  towards  the  cicatrix  of  the  subjacent  cellular  tissue, 
a  pidl  is  exerted  upon  the  e^X'lid,  wdiich  will  first  draw 
down  its  tarsal  edge,  and  then  graduall}'  evei't  it. 

Two  forms  of  ectropion  may  be  recognized,  either  of 
which  may  be  produced  by  the  same  cause,  the  ditt'erence 
being  only  in  degree. 

1,  Where  there  is  2i  partial  eversion  of  the  eyelid,  with 
a  thickened  and  fungoid  condition  of  the  conjunctiva, 

2,  Where  the  ej'elid  is  entirely  everted,  its  conjunctival 
surface  being  completely  exposed. 

The  first  form  is  most  frequently  caused  by  the  cicatri- 
zation of  a  wound  in  the  neighborhood  of  the  e3'elids ; 
whilst  the  second  is  generally  the  result  of  an  absolute 
destruction  of  a  portion  or  the  whole  of  the  skin  of  the 
lid  itself. 

Treatment  of  Ectropion. — 'In  considering  what  are  the 
best  means  of  restoring  an  eyelid  with  ectropion  to  its 
normal  condition,  it  is  necessary  first  to  determine  the 
relative  changes  which  are  produced  by  this  deformity  on 
the  different  parts  of  the  lid.  1,  The  e3elid  is  more  or 
less  everted.  2.  As  a  consequence  of  this,  the  punctum 
lachrymale  is  displaced:  it  is  drawn  awa^' from  its  proper 
relationship  with  the  globe,  so  that  it  has  ceased  to  act 
as  a  conduit  for  the  tears,  3,  The  tarsal  edge  of  the 
lid  is  more  or  less  elongated,  according  to  the  extent  of 
the  eversion.  4.  In  many  cases  the  exposed  conjunctiva 
is  hj'^pertrophied  and  thickened. 

In  a  mild  case  of  ectropion  these  defects  will  be  only 
slightly  inarked,  and  possibly  one  or  other  of  them  may 

30* 


354  DISEASES    OF   THE    EYELIDS. 

be  absent;  but  when  there  is  a  great  eversion  of  the  lid, 
they  will  probably  be  all  present  and  distinctly  seen.  In 
treating  of  each  of  these  defects,  I  will  take  them  in  the 
order  in  which  it  would  be  wise  to  proceed  in  an  operation 
for  their  relief. 

1.  If  the  2^unctum  lachrymale  is  dii<])Iaced,,  and  drawn 
away  from  the  globe,  the  canaliculus  should  be  slit  up  so 
as  to  convert  it  into  a  canal  along  which  the  tears  ma_y 
flow  into  the  sac.  This  is  readily  accomplished  by  one  of 
the  methods  recommended  at  page  335. 

2.  If  the  exposed  conjiuietiva  is  much  thickened  and 
hypertrojMed^  the  prominent  excrescent-looking  portion 
should  be  excised.  This  is  most  easily  done  b}^  seizing 
hold  of  the  piece  of  conjunctiva  which  is  to  be  removed, 
with  a  i)air  of  fine-toothed  forceps,  and  cutting  it  ofl'  with 
a  pair  of  small  scissors  curved  on  the  flat.  The  contrac- 
tion which  accomi)anies  the  cicatrization  of  the  conjunc- 
tiva draws  the  edge  of  the  eyelid  inwards,  and  helps  Aery 
materially  to  restore  it  to  its  natural  position. 

3.  If  the  tarsal  edge  of  the  lid  is  elongated,  it  must  be 
shoitened  before  the  lid  can  be  restored  to  its  proper  po- 
sition. This  lengthening  of  the  tarsal  margin  is  due  to 
the  constant  pull  which  has  been  exerted  upon  it  during 
the  contraction  and  cicatrization  of  the  wound  which  has 
caused  the  ectropion.  To  remedy  this  defect,  a  V-shaped 
piece  of  the  edge  of  the  lid  may  be  excised  with  a  fine 
scalpel.  The  lips  of  the  wound  are  then  to  be  brought 
together  with  fine  pins  and  twisted  sutui'es,  taking  care 
that  one  of  the  needles  is  inserted  close  to  the  tarsal  edge, 
so  that  an  accurate  apposition  of  the  corresponding  sur- 
faces is  secured.  A  portion  of  the  tarsal  margin  ma}'  thus 
be  removed  from  any  part  of  its  length,  but  in  most  cases 
it  is  advisable  to  make  the  excision  from  the  extreme  end 
close  to  the  outer  cauthus.  The  edges  of  the  wound  are 
brought  more  easily  and  accurately  together  than  Avlien 


ECTROPION.  355 

the  part  excised  is  near  the  centre  of  the  lid,  and  the 
scar  which  is  left  is  much  less  noticeable. 

4,  To  relieve  the  eversion  of  the  eyelid^  many  operations 
have  been  suggested  and  practised.  When  the  ectropion 
depends  upon  a  cicatrix,  either  of  the  skin  in  the  neigh- 
borhood of  the  orbit  or  of  the  lid  itself,  the  first  endeavor 
should  be  to  free  the  e3'elid  from  the  influence  of  the  scar 
which  binds  it  down.  This  can  be  often  readily  accom- 
plished; the  great  difficulty  is  to  prevent  a  reunion  of  the 
parts,  and  a  return  of  the  deformit}^ 

a.  Whei'e  thei'e  is  coviplete  or  partial  eversioii  dej^endent 
on  a  cicatrix  at  a  short  distance  from  (he  lid. — For  con- 
venience of  description,  I  will  deal  with  a  case  in  which 
the  lower  lid  is  the  one  affected.  The  same  plan  of  treat- 
ment, modified  according  to  circumstances,  will  be  apjtli- 
cable  to  ectropion  of  the  upjjfer  lid.  If  the  ectropion  is 
2)artial,  and  due  to  a  small  cicatrix  which  is  only  adherent 
to  a  very  limited  area  of  the  cellular  tissue  beneath  it, 
while  around  the  scar  the  skin  will  glide  easil}^  over  the 
subjacent  tissues,  it  will  be  sufficient  first  to  free  the  deep 
adhesions  of  the  cicatrix  by  subcutaneous  division.  A 
tenotom}'  knife  is  to  be  introduced  beneath  the  integu- 
ment, at  a  short  distance  from  the  scar,  and  by  a  few 
semicircular  sweeps  the  union  between  it  and  the  cellu- 
lar tissue  will  be  parted.  If  this  is  satisfactorily  accom- 
plished, the  skin  will  glide  with  fieedom  over  the  paits 
to  which  it  was  before  adherent.  The  tarsal  edge  of  the 
lid  should  now  be  shortened  in  the  manner  already  de- 
scribed ;  and  if  the  exposed  conjunctiva  is  much  thickened, 
a  portion  of  it  also  should  be  excised.  By  these  means, 
the  lid  will  be  restored  to  its  normal  position,  and  as  the 
scar  will  be  lifted  from  its  original  site,  the  chance  of  its 
reuniting  to  the  parts  from  which  it  has  been  severed 
will  be  diminished.  In  the  daily  dressing  of  the  wounds, 
the  lids  should  be  well  supported  Avith  a  pad  of  lint,  to 


356  DISEASES  OF  THE  EYELIDS. 

prevent  the  cicatrix  being  again  drawn  down  to  its  former 
position. 

ft.  If  the  ectropion  is  severe.,  and  the  cicatrix  which  has 
caused  it  is  dense  and  firmly  attached  to  the  subjacent 
parts,  a  different  proceeding  must  be  adopted.  One  very 
excellent  mode  of  treatment  is  by  including  in  a  T-shaped 
incision  the  cicatrix,  which  is  to  be  separated  by  a  few 
strokes  of  the  scalpel  from  all  its  adhesions  to  the  under- 
lying parts.  The  triangular-shaped  piece  of  skin  in  which 
is  the  cicatrix  is  then  to  be  pushed  upwards,  whilst  the 
lower  edges  of  the  V  wound  are  united  by  two  pins  and 
twisted  sutures,  so  as  to  convert  the  Y,  when  the  parts  are 
brought  together,  into  a  Y.  The  everted  lid  will  thus  be 
raised ;  but  in  order  to  keep  it  in  position  its  tarsal  edge 
should  be  shortened  at  the  outer  canthus,  removing  at  the 
same  time  a  small  piece  of  the  margin  of  the  upper  lid.  to 
which  it  should  be  united  by  pins  and  twisted  sutures.  If 
the  conjunctiva  is  much  thickened,  a  portion  of  it  may  be 
excised  before  shortening  the  lid. 

In  most  of  the  operations  for  the  relief  of  ectropion  the 
chance  of  success  will  be  materially  increased  b}'  adopting 
the  expedient,  first  suggested  and  practised  b}^  Mr.  Bow- 
man, of  temporarily  uniting  a  portion  of  the  correspond- 
ing tarsal  edges  of  the  upper  and  lower  lids.  This  is  to 
be  accomplished  by  paring  the  thinnest  possible  shaving 
from  the  opposed  tarsal  margins,  and  then  fastening  them 
together  with  a  single  fine  suture.  Immediate  union  gen- 
erally follows,  and  the  lids  are  allowed  to  remain  closed 
for  some  weeks  or  months,  until,  indeed,  all  the  contrac- 
tion and  cicatrization  consequent  on  the  operation  for  the 
ectropion  has  passed  away.  "When  it  is  desirable  to  part 
the  lids,  the  bond  of  union  may  be  divided  on  a  director 
with  a  single  stroke  of  a  scalpel. 

y.  In  those  cases  where  much  of  the  integvment  of  the 
eyelid  has  been  destroyed,  and  complete  eeersion  of  it  has 


ECTROPION.  357 

folloAved,  it  is  seldom  that  the  lid  con  be  permniiently  re- 
stored to  its  natural  position  without  some  plastic  opei'a- 
tion.  After  the  lid  has  been  dissected  from  the  adhesions 
which  bind  it  doAvn,  and  has  been  replaced  over  the  eye, 
a  large  granulating  surface  will  be  left,  which,  unless  cov- 
ered over  by  new  skin,  borrowed  from  a  neighboring  j^art, 
will  cause,  during  cicatrization,  a  return  of  the  ectropion. 

I  will  not  attempt  to  describe  the  different  operations 
which  have  been  either  suggested  or  performed  for  the 
making  of  a  new  eyelid.  Each  case  presents  peculiari- 
ties of  its  own,  for  which  no  special  directions  can  be 
given.  The  result  of  the  operation  depends  very  much 
on  the  ingenuity  of  the  surgeon  in  designing  one  fitted  for 
the  case,  and  on  his  dexterity  in  carr3'ing  out  neatly  the 
details  which  his  mind  has  conceived. 

A  few  general  directions  may,  however,  be  useful.  If 
the  ectropion  be  of  the  upper  lid,  it  is  generally  most 
convenient  to  borrow  the  skin  from  the  side  of  the  fore- 
head ;  but,  when  the  lower  lid  is  the  one  affected,  it  may 
be  most  easily  obtained  from  either  the  side  of  the  cheek 
or  the  inner  side  of  the  nose. 

1.  Before  attempting  a  plastic  operation  for  the  forma- 
tion of  a  new  eyelid,  sufficient  time  should  be  allowed  to 
elapse  after  the  iujuiy  for  the  skin  in  the  neighborhood 
of  the  eye  to  have  recovered  as  far  as  possible  its  health}^ 
elasticity'  and  softness.  All  thickening  and  induration  of 
the  subjacent  cellular  tissue  should  have  passed  away,  and 
the  skin  should  glide  readil}'  over  the  parts  beneath  it. 

2.  After  having  by  dissection  restored  the  lid  to  its 
proper  position,  the  size  of  the  surface  to  be  covered 
with  the  borrowed  skin  should  be  accurately  noted ;  and 
the  piece  which  has  to  be  taken  from  the  temple,  or  else- 
Avlicre,  should  be  of  larger  dimensions  than  is  apparently 
recpiired,  as  the  skin  contracts  about  one-sixth  when  de- 
tached from  the  part  it  originally'  occupied.     It  must  also 


858  DISEASES    OF    THE    EYELID>. 

be  i-ememl)ertMl  lliat  even  if  it  is  a  little  too  large,  a  fur- 
ther contraction  of  it  will  take  place  during  the  healing 
process,  which  will  reduce  it  to  its  required  size. 

3.  (jrreat  care  should  be  taken  to  leave  a  good  pedicle 
through  which  the  vascular  sujiply  of  the  new  lid  may  be 
maintained  until  it  ha»s  become  united  with  the  parts  be- 
neath it,  and  a  fresh  source  of  nourishment  has  been  es- 
tablished. It  is  also  advisable,  in  adapting  the  skin  to 
the  lid,  to  avoid  twisting  the  pedicle  on  itself  more  than 
is  absolutely  necessary. 

4,  Before  uniting  the  edges  of  the  new  lid  to  the  sur- 
rounding skin,  all  bleeding  should  be  arrested.  Nothing 
tends  more  to  delay  primar^^  union  than  a  clot  of  blood 
between  the  opposed  surfaces. 

In  nearl}"  all  cases  where  a  plastic  operation  is  required, 
it  will  be  well  to  shorten  the  tarsal  margin  of  the  lid  in 
the  manner  already  described,  so  as  to  slightly  diminish 
the  size  of  the  palpebral  aperture. 

If  the  exposed  portion  of  the  conjunctiva  is  much  thick- 
ened and  granular,  a  portion  of  it  also  should  be  removed 
with  a  pair  of  curved  scissors. 

Having  completed  the  operation,  a  layer  of  wet  lint 
should  be  laid  over  the  lids,  upon  which  a  light  compress 
of  cotton-wool  should  be  fastened  with  one  or  two  turns 
of  a  roller,  for  the  purpose  of  keeping  the  parts  in  appo- 
sition, and  of  maintaining  a  certain  amount  of  warmth. 

PARALYTIC    AND    SPASMODIC    AFFECTIONS    OF    THE    EYELIDS. 

Ptosis,  or  a  drooping  of  the  upper  ej'elid  over  the  eye, 
may  be  due: 

«.  To  paralysis  of  the  third  nerve,  or  to  that  branch  of 
it  which  supplies  the  levator  palpebnii  superioris  muscle. 

,i.  To  injury  of  the  levator  palpebrie. 

y.  It  may  be  congenital. 


PTOSIS.  359 

'1.  Partial  ptosis  may  be  occasionally  mot  with  in  old 
people,  apparently  dependent  on  a  redundancy  of  wrinkled 
integument. 

Ptosis  may  be  either  complete  or  partial.  In  the  former, 
the  greater  part  of  the  cornea,  and  the  whole  of  the  pupil 
is  covered  by  the  lid,  which  cannot  be  raised  by  the  will 
of  the  patient ;  in  the  latter,  the  pupil  is  only  partially 
hidden,  and  the  lid  can  be  slightly  uplifted  by  a  strong 
effort. 

The  causes  which  ma}'  produce  paralysis  of  the  third 
nerve,  or  of  one  or  more  of  its  branches,  have  been  already 
mentioned  in  the  section  on  Paralytic  Affections  of 
THE  Muscles  of  the  Eye,  page  302. 

Ptosis  from  injury  may  be  induced  by  a  wound  of  the 
upper  lid,  lacerating  the  levator  palpebr^e  muscle  so  as  to 
impair  its  function. 

TreatmeM. — In  recent  cases  of  ptosis  arising  from  pa- 
ralysis of  the  third  nerve,  or  of  the  filament  of  it  which 
goes  to  the  levator  palpebrse,  the  course  of  treatment 
recommended  for  paralytic  affections  of  the  ocular  mus- 
cles, page  311,  must  be  followed.  If,  however,  medicinal 
agents  fail,  relief  must  be  sought  from  some  operative 
proceeding.  For  congenital  and  traumatic  ptosis,  inter- 
nal medicines  will  be  of  no  avail. 

In  deciding  on  an  operation  for  ptosis,  it  is  a  question 
w'hat  amount  of  drooping  of  the  lid  will  render  surgical 
interference  advisable.  My  own  feeling  is,  that  if  the 
paral3'sis  is  partial,  and  without  any  effort  on  the  part  of 
the  patient  half  the  pupil  is  exposed,  no  operation  should 
be  performed.  If,  however,  the  palsy  is  complete,  or  only 
a  portion  of  the  pupil  can  be  uncovered  by  a  great  effort, 
an  attempt  should  be  made  to  permanently  raise  the  lid, 
and  place  it,  as  much  as  possible,  under  the  dominion  of 
the  occipito-frontalis  muscle. 

The  various  operations  for  ptosis  are  based  on  the  one 


360  DISEASES    OF    THE    EYELIDS. 

endeavor  to  place  the  up[)er  lid  uuder  the  action  of  those 
fibres  of  the  occipito-frontalis  which  are  mingled  with  the 
orbicularis.  This  end  may  be  accomplished  in  several 
ways.  The  following  is,  however,  the  most  satisfactory 
operation. 

A  horizontal  incision  is  first  made  through  the  skin  of 
the  upper  lid,  about  2'"  from  its  tarsal  margin,  and  along 
its  entire  length;  the  lips  of  the  wound  are  then  sepa- 
rated b}'  drawing  them  apart,  and  by  a  little  dissection 
beneath  the  integument,  until  a  considerable  portion  of 
the  orbicularis,  covering  the  lid,  is  exposed ;  this  is  then 
seized  with  a  pair  of  forceps,  and  a  horizontal  strip  of  the 
muscle,  about  a  quarter  of  an  inch  in  width,  is  excised. 
The  edges  of  the  wound  are  then  brought  together  with 
three  sutures,  each  of  which  is  made  to  pass  through  the 
upper  cut  portion  of  the  orbicularis.  In  this  manner  the 
lower  part  of  the  lid  is  brought  under  cover  of  the  upper 
fibres  of  the  orbicularis,  into  which  the  middle  and  outer 
fibres  of  the  occipito-frontalis  are  inserted,  and  thus  a 
certain  amount  of  control  over  the  upper  lid  is  given  to 
that  muscle.  In  addition  to  this,  the  power  of  closing 
the  lids  is  diminished  b}-  the  excision  of  the  broad  baud 
of  the  orbicularis. 

An  attempt  to  relieve  ptosis  b}'  simply  excising  a  piece 
of  the  skin  of  the  upper  lid,  is  generally  unsuccessful. 

Paralysis  of  the  Orbicularis  Muscle — Lagophthal- 
mos — is  caused  by  paralysis  of  the  portio  dura  of  the 
seventh  nerve,  and  is  usually  associated  with  pais}'  of  the 
other  facial  muscles.  It  is  generall}^  due  to  some  local 
affection  of  the  portio  dura,  either  as  it  traverses  the  bony 
canal  in  its  passage  from  within  the  skull,  or  after  it  has 
emerged  from  the  st3-lo-mastoid  foramen.  It  may,  also, 
arise  from  disease  of  the  brain,  as  in  cases  of  hemiplegia. 
According  to  Dr.  Trousseau,  it  is  when  the  facial  palsy  is 


PARALYSIS    OF    THE    OHBICULARIS    MUSCLE.        361 

dependent  on  local  causes,  and  not  on  brain  disease,  that 
the  paral^'sis  of  the  orbicularis  is  most  complete.  The 
knowledge  of  this  fact  is  used  by  him  as  a  point  in  diag- 
nosis; "hence,"  he  says,  "if  a  hemiplegic  patient  be  asked 
to  shut  his  eye,  he  does  it  completelj^  enough  to  hide  the 
globe  of  the  eye,  whilst  the  eyeball  remains  uncovered  in 
cases  of  paralysis  of  the  seventh  pair."* 

The  diseases  which  lead  to  paralysis  of  the  portio  dura 
of  the  seventh  nerve  are,  syphilis,  rheumatism,  and  goitt, 
either  of  which  may  cause  pressure  on  the  trunk  of  the 
nerve,  from  an  exudation  in  its  immediate  vicinity,  or 
from  an  inflammatory  thickening  of  the  nerve-sheath. 
Palsy  of  the  facial  ma}^  also  be  induced  by  the  nerve 
being  compressed  by  tumors  near  the  angle  of  the  jaw, 
by  exposure  of  the  side  of  the  face  to  cold  currents  of  air, 
and  from  inj^r3^ 

The  sympfovi.H  of  palsy  of  the  orbicularis  are,  an  inabil- 
ity to  close  the  e^'elids,  and,  in  exceptional  cases,  where 
the  paralysis  is  complete,  the  patient  has  not  the  power 
even  to  approximate  them.  A  peculiar  stare  is  thus  given 
to  the  ej'e,  from  which  the  affection  has  received  the  name 
of  lacjophthahnos^  or  "hare's  ej^e."  The  lower  lid  having 
lost  the  support  of  the  orbicularis,  falls  away  from  the 
globe,  and  the  punctum  becoming  everted,  the  tears  flow 
over  the  cheek,  and  the  tarsal  margins  are  apt  to  become 
excoriated.  The  most  distressing  symptoms,  however, 
from  a  loss  of  power  of  the  orbicularis,  arise  from  the  ex- 
posure of  the  eye,  from  the  imperfect  closure  of  its  lids, 
to  the  contact  of  foreign  particles,  and  the  irritating  ef- 
fects of  wind  and  glare. 

The  treatment  of  palsy  of  the  orbicularis  is  the  same  as 
that  described  for  the  paral3tic  affections  of  the  ocular 

*  Trousseau's  Clinical  Medicine,  translated  by  the  Sj'denham 
Society,  vol.  i,  p.  3. 

31 


362  DISEASES    OF   THE    EYELIDS. 

muscles,  see  page  311.  ^^'llen,  however,  the  pamlysis  of 
the  facial  nerve  is  clue  to  some  local  cause,  as  the  presence 
of  a  tumor  or  an  enlarged  gland  near  the  exit  of  the  nerve 
from  the  stylo-mastoid  foramen,  special  attention  must  be 
devoted  to  its  removal.  To  protect  the  eye  from  exposure, 
a  shade  or  some  other  light  covering  should  be  worn  bj'' 
the  patient. 

Blepharospasm,  or  spasmodic  contraction  of  the  orbic- 
ularis, causing  the  lids  to  be  tiglith*  grasped  upon  the 
globe,  occurs  in  all  affections  of  the  eye  in  which  photo- 
phobia is  a  prominent  symptom.  It  is  caused  by  some 
irritation  of  the  fifth  nerve,  inducing  a  reflex  contraction 
of  the  orbicularis. 

a.  It  is  met  with  in  severe  cases  of  the  purulent  oph- 
thalmia of  infants  ;  and  in  most  of  the  diseases  of  tlie 
cornea,  especially  those  which  are  marked  bj'  ulceration. 
The  continued  spasm  will  sometimes  cause  entropion,  by 
folding  in  the  tarsal  margins  of  the  lids.  This  spasmodic 
entropion  generally  happens  to  the  lower  lid. 

/?.  It  frequently-  occurs  in  granular  ophthalmia,  when 
from  spasm  of  the  orbicularis  it  is  often  difficult  to  evert 
the  lids  to  treat  the  granulations. 

•f.  It  may  accompany  the  simple  hypertesthesia  of  the 
retina  which  is  occasionally  seen  in  amemia  and  debility-. 

8.  It  is  present  in  most  cases  of  lodgement  of  foreign 
bodies  in  the  ej^e. 

e.  It  may  also  be  associated  with  neuralgia  of  the  fifth 
nerve,  especially  of  its  supra-orbital  branch. 

The  treatment  must  consist  in  the  endeavor  to  arrest 
the  spasm  by  the  removal  of  the  source  of  the  irritation. 
"When  a  foreign  body  is  suspected,  the  lids  should  be  care- 
full}^  everted,  and  the  surface  of  the  cornea  scanned  over, 
as  if  a  particle  of  grit  or  dust  can  be  detected,  the  taking 
it  away  will  at  once  remove  all  spasm. 


NICTITATION.  oGo 

For  the  mode  of  dealing  with  the  various  aftectioiis  of 
the  cornea,  or  Avith  granulations  of  the  lid,  the  reader 
must  refer  to  the  sections  under  their  respective  headings. 
In  si)asm  of  the  orbicularis  arising  from  anaemia  and  de- 
bilit}',  cinchona  with  small  doses  of  the  tincture  of  bella- 
donna will  be  found  ver^'  useful,  or  some  of  the  pi'epara- 
tions  of  iron  may  be  ordered.  The  eyes  in  all  cases  should 
be  protected  from  exposure  to  glare  b}'  dark  neutral-tint 
glasses,  and  if  the  intolerance  of  light  is  severe,  a  few 
drops  of  the  solution  of  atropine  (F.  13)  may  be  dropped 
twice  or  three  times  a  day  into  the  eye. 

When  the  blepharospasm  is  associated  with  neuralgia 
of  one  of  the  branches  of  the  fifth  nerve,  quinine  should 
be  given  in  full  doses,  and  the  pain  be  relieved  by  the  sub- 
cutaneous injection  of  from  gr.  i  to  gr.  ^  of  the  acetate  of 
morphia  (F.  24),  according  to  the  age  and  suffering  of 
the  patient.  If  pressure  with  the  finger  on  the  infra-  and 
supra  orbital  branches  of  the  fifth  nerve  will  decide  which 
of  the  two  is  the  cause  of  the  reflex  spasm  of  the  orbic- 
ularis, that  nerve  ma}^  be  subcutaneously  divided  with  a 
tenotomy  knife. 

Nictitation,  or  a  Irequent  blinking  of  the  lids,  is  a 
peculiar  nervous  affection,  in  some  patients  quite  involun- 
tary, and  in  others  only  to  be  suppressed  by  a  strong 
effort  of  the  will.  It  is  sometimes  associated  with  chorea  ; 
it  then  becomes  most  manifest  when  the  patient  is  self- 
•  conscious.  In  extreme  cases  the  nictitation  ma}'^  be  so 
frequent,  and  beyond  the  control  of  the  will,  as  to  inter- 
fere with  all  duties  which  require  a  close  application  of 
the  e3'es. 

Treatment. — If  an}*  source  of  irritation  can  be  detected 
to  account  for  this  reflex  action  of  the  orbicularis,  it  must 
be  at  once  removed.  Inquiry  should  be  made  concerning 
the  functions  of  the  visceral  organs,  and  means  be  taken 


364  DISEASES    OF    THE    EYELIDS, 

to  rectify  any  derangement.  If  there  is  chorea,  some 
preparation  of  iron  will  usually  do  good,  and  esj^ecialh' if 
the  patient  is  ordered  at  the  same  time  bracing  country 
or  sea  air  with  a  cold  siiongiiig  bath  every  morning. 

ULCERATIONS    OF    THE    EYELIDS. 

Syphilitic  Ulcers  of  the  Lid  are  generally  second- 
ary ;  it  is  rare  to  meet  with  the  primary  sore  in  this  lo- 
cality. I  have,  however,  seen  a  chancre  on  the  eyelid;  it 
was  in  a  child  under  two  years  of  age,  and  was  followed 
by  a  copious  secondary  eruption.  No  doubt  the  virus 
■was  conveyed  to  the  lid  through  the  finger  of  the  mother 
or  the  nurse  of  the  child. 

Secondary  syphilitic  sores  on  the  lid  resemble  very 
much  in  appearance  epithelial  ulcers,  for  which  they  may 
be  easilj^  mistaken.  They  usually'  commence  close  to  the 
tarsal  margin,  which  they  partially  destroy,  leaving  a 
notch  which  is  very  characteristic  of  the  disease.  The 
ulcer  will  often  heal  at  the  point  where  it  first  commenced, 
whilst  at  the  same  time  it  extends  itself  in  the  opposite 
direction.  In  this  respect  it  ditiers  from  the  rodent  or 
epithelial  sore,  in  which  there  is  no  real  repair  of  any 
portion  of  the  ulcerated  surface.  The  previous  history  of 
the  patient,  when  it  can  be  truthfully  obtained,  is  also  an 
imi)ortant  guide  in  the  diagnosis;  but  in  cases  of  doubt  a 
week  or  ten  days'  treatment  with  anti-sj'philitic  remedies 
will  usuall}^  decide  the  true  origin  of  the  disease. 

Ti'eatment As  an  application  to  the  sore,  a  weak  mer- 
curial ointment  (F.  102,  103).  Internally,  a  mixture  with 
iodide  of  potassium  (F.  74),  and  pil.  h^drarg.  subchlorid. 
comp.  gr.  5  eveiy  other  night,  or  the  liq.  hydrarg.  per- 
chlorid.  may  be  given  (F.  SO)  two  or  three  times  daily,  or 
the  iodide  of  potassium  and  i)erchloride  of  mercury  may 
be  combined  in  the  same  mixture.     If  the  patient  be  a 


CANCER    OF    THE    EYELID.  o(J5 

chilli,  the  hydrarg.  cum  creta  (F.  121)  must  be  given 
every  uight,  or  night  and  morning,  and,  during  the  day, 
small  doses  of  the  mist,  ferri  iodid.,  or  the  mist,  potassii 
iodidi  cum  ferro  (F.  114,  115), 

KoDENT  Cancer  of  the  EIyelid  generally  commences 
as  a  small  piuiijle  in  the  skin,  near  the  tarsal  edge,  which 
idcerates  and  then  scabs  over,  but  does  not  heal.  It  usu- 
ally gives  little  or  no  pain  ;  indeed,  the  attention  of  the 
patient  is  often  called  to  it  for  the  first  time  only  by  a 
sense  of  itching,  which  causes  him  to  scratch  it  with  one 
of  his  tinger-nails ;  and  to  this  scratch  is  frequently  attrib- 
uted all  the  after  progress  of  the  disease.  Examined  be- 
tween the  fingers,  the  ulcerated  surface  will  be  found  to 
have  a  hard  base  and  margin.  It  is  not  simply  an  ulcer, 
but  it  is  a  new  growth  or  infiltration  in  the  skin,  which 
induces  ulceration  of  the  surface  as  fast  as  the  deposit 
takes  place.  In  its  onward  slow  creeping  progress,  more 
skin  is  involved,  and  the  dimensions  of  the  ulcer  are  in- 
creased ;  but  repair  does  not  follow  destruction.  There 
is  no  true  cicatrization  in  rodent  cancer,  although  here 
and  there  parts  of  the  wound  may  be  imperfectly  scabbed 
over.  For  a  detailed  account  of  all  that  can  be  said  of 
rodent  cancer,  I  must  refer  the  reader  to  the  excellent 
monograph  on  this  subject  by  my  friend  and  colleague, 
Mr.  Charles  II.  Moore.  For  the  treatment  of  rodent 
cancer,  and  the  diagnosis  between  it  and  epithelial  can- 
cer, see  the  next  section. 

p]piTHELiAL  Cancer  of  the  Eyelid  closel}^  resembles 
the  rodent  ulcer,  for  which  it  ma}^  be  easily  mistaken. 
There  are,  however,  certain  characteristics  which  may 
serve  to  distinguish  the  one  from  the  other.  Epithelial 
cancer  usually  selects  as  its  starting-point  a  locality  where 
the  skin  joins  the  mucous  membrane ;  thus,  the  edge  of 

31* 


'666  DISEASES    OF    THE    EYELIDS. 

the  eyelid  near  the  caniiicle  mid  the  lip  are  favorite  sites 
for  tlie  disease;  whereas,  rodent  cancer  adcai/s  starts  in 
the  skin.  Ei)ithelioma  also  invades  the  lymphatics  and 
involves  the  neighboring  glands,  whilst  in  rodent  cancer 
the  glands  are  unaffected.  The  first  appearance  of  epi- 
thelial cancer,  and,  up  to  a  certain  stage,  its  after  pro- 
gress, are  very  similar  to  rodent  cancer,  but  in  the  later 
periods  of  the  disease  there  is  a  marked  difference.  JNIr. 
Moore  says:  "Advanced  cases  of  the  two  diseases  could 
hardly  be  confounded.  There  is  at  that  period  much 
more  solid  substance  in  the  epithelioma,  and  the  gaps 
which  it  makes  by  destroying  the  normal  parts,  though 
equally  great,  are  less  openly  cavernous  than  in  the  ro- 
dent cancer."* 

Treatment  of  Epithelial  and  Bodent  Cancer. — Excise 
the  whole  of  the  disease,  carrying  the  incision  into  the 
sound  skin,  so  as  to  be  certain  that  none  of  the  morbid 
growth  is  left  behind.  Arrest  all  hemorrhage  by  means 
of  ligature,  and  if  necessary  with  the  actual  cautery,  and 
then  thoroughly  soak  the  surface  with  a  solution  of  chlo- 
ride of  zinc,  gr.  40  ad  aquse  5  1,  or  touch  it  over  with  the 
solid  chloride  of  zinc.  A  little  simple  dressing  is  now  to 
be  placed  over  the  wound,  which  should  be  allowed  to 
heal  by  granulation.  If  in  the  course  of  cicatrization  a\\y 
suspicious-looking  granulations  spring  up,  they  must  be 
at  once  desti'oyed  b}'  sprinkling  on  them  a  little  of  the 
chloride  of  zinc  powder  (F.  6).  There  are  other  ways  of 
dealing  with  rodent  and  epithelial  cancer,  such  as  destroy- 
ing them  with  the  strong  nitric  acid,  or  with  the  liq.  hy- 
drarg.  nitrat.  acid,  or  with  the  chloride  of  zinc,  but  I 
much  prefer  first  excising  the  disease,  and  then  using  the 
chloride  of  zinc  in  the  AvaA'  I  have  described. 

*  Rodent  Cancor,  p.  24. 


TUMORS.  3G7 


TUMORS    OF    THE    EYELIDS. 

Tarsal  Cysts — Meibomian  cysts —  Chalazion — usually 
occur  as  small  isolated  tumors  in  the  upper  and  lower 
eyelids.  There  may  be  two  or  three  of  them  in  the  same 
lid,  but  they  are  independent  growths,  and  in  no  way 
connected.  They  generally  grow  to  about  the  size  of  a 
small  pea,  but  they  will  occasionally  attain  much  larger 
dimensions.  They  are  developed  from  the  follicles  of  the 
Meibomian  glands,  of  which  they  seem  to  be  a  morbid 
expansion.  To  the  linger  they  feel  like  small  shot  in  the 
lid  ;  and  externally  they  give  a  nodulated  appearance, 
which  makes  the  patient  anxious  to  be  rid  of  them.  They 
vary  in  consistence,  and  in  the  character  of  their  contents. 
In  some  instances  they  are  filled  with  a  solid  or  thick  ge- 
latinous material,  whilst  in  other  cases  their  contents  are 
either  a  transpai'ent  or  semi-opaque  curdy  fluid,  or,  if  the 
cyst  has  been  inflamed,  pus.  When  first  noticed,  a  tarsal 
cyst  is  usually  small  and  firm ;  as  it  grows,  it  approaches 
the  inner  surface  of  the  lid,  its  contents  undergo  a  degen- 
erative softening,  and  the  conjunctiva  immediatelj'  cover- 
ing the  tumor  becomes  thinned  and  of  a  bluish  color.  In 
this  state  the  cyst  may  remain  for  many  months  or  even 
years  without  any  apparent  change,  when,  from  some  un- 
explained cause,  it  may  inflame  and  supjjurate. 

Treatment. — The  best  time  for  operating  on  a  tarsal 
C3'st  is  when  the  conjunctiva  covering  it  looks  thin  and 
bluish,  as  its  contents  are  then  more  easily  turned  out 
than  at  an  earlier  stage  of  the  disease.  The  surgeon 
standing  behind  the  head  of  the  patient,  who  is  seated  on 
a  chair,  should  with  one  finger  evert  the  lid,  and  with  a 
cataract  knife  make  an  incision  through  the  length  of  the 
conjunctival  wall  of  the  cyst  in  a  line  parallel  with  the 
tarsal  margin ;  if  the  tumor  is  large,  another  smaller  in- 


308  DISEASES    OF    THE    EYELIDS. 

cision  may  also  be  made  through  it  at  right  angles  to 
the  first.  With  a  fine  scoop  the  whole  of  the  contents  of 
the  C3'st  are  then  to  be  evacuated,  and  this  is  best  done 
by  giving  to  the  scoop  a  slight  rotatory  movement,  Avhich 
helps  to  break  up  the  material  within  the  cyst,  whilst  it 
also  scratches  the  lining  membrane,  and  sets  up  sutlicient 
inflammatory  action  to  cause  the  obliteration  of  the  sac. 
For  two  or  three  days  succeeding  the  operation  a  probe 
should  be  passed  along  the  line  of  the  incision,  to  pre- 
vent the  lips  of  the  wound  uniting  before  the  cavity  is 
closed.  When  the  contents  of  the  cyst  are  so  solid  that 
the  whole  cannot  be  shelled  out,  it  is  a  good  plan  to  apply 
to  the  interior  of  the  sac  a  probe  charged  with  nitrate  of 
silver;  free  suppurative  action  will  be  thus  induced,  and 
in  all  probability  a  cure  will  be  effected.  No  attempt 
should  ever  be  made  to  dissect  out  a  tarsal  cyst  by  an 
incision  through  the  skin  of  the  lids. 

NiEVUS  OF  THE  E  YE  LID  may  be  limited  to  the  skin, 
or  it  may  include  the  whole  thickness  of  the  lid,  and 
extend  through  the  palpebral  cartilage.  Sometimes  it  is 
an  extension  of  a  similar  but  larger  growth  within  the 
orbit,  with  which  it  freel}-  communicates. 

Treatment. — In  treating  naevi  of  the  lid  it  is  of  great 
importance  to  avoid  destruction  of  healthy  skin,  lest  a 
bad  ectropion  should  follow  the  means  adopted  for  the 
cure  of  the  disease.  A  small  supei'ficial  arterial  na'vus 
may  be  often  dissected  out ;  or  it  may  be  destroyed  by 
the  actual  cautery,  using  the  finely  pointed  cautery  made 
specially  for  eye  purjjoses,  with  which  the  naevus  may 
be  touched  at  two  or  three  points.  Where  the  growth 
extends  more  deeply,  one  or  two  threads  soaked  in  a 
strong  solution  of  the  perchloride  of  iron  may  be  drawn 
through  it,  and  be  allowed  to  remain  until  suppuration 
has  connnenced,  when  they  may  be  removed. 


DERMOID    CYSTS — EPICANTHUS.  369 

When  the  iioevus  is  too  large  to  be  dealt  with  in  either 
of  the  ways  mentioned,  it  must  be  ligatured.  The  plan 
recommended  by  some  surgeons  of  injecting  nrevi  with 
solutions  of  iron  or  of  tannin  is  dangerous  to  life,  and 
should  not  be  practised.  There  are  several  cases  on 
record  where  this  mode  of  treatment  has  terminated 
rapidly  in  death. 

Sebaceous  or  Dermoid  Cysts  occur  usually  in  two  lo- 
calities,—  at  the  upper  and  outer  margin,  and  at  the 
lower  and  inner  edge  of  the  orbit,  just  over  the  nasal 
process  of  the  superior  maxillary  bone.  They  are  con- 
genital, and  although  the}'  often  appear  to  the  touch  to 
be  superficial  and  loosely  attached,  they  are  in  reality 
placed  deeply,  lying  in  a  depression  of  the  bone,  beneath 
the  orbicularis,  and  very  adherent  to  the  surrounding 
parts.  The}'  are  filled  with  sebaceous  matter,  and  con- 
tain numerous  fine  hairs. 

Treatment. — They  should  be  dissected  out  through  a 
single  incision,  made  over  the  centre  of  the  prominence 
of  the  tumor,  and  in  a  line  corresponding  with  the  curves 
of  the  brow  or  the  orbit.  Care  should  be  taken  to  remove 
the  whole  of  the  cyst,  as  when  portions  of  it  are  left,  it 
will  sometimes  re-form.  The  operation,  although  appa- 
rentl}'  ver}'  slight,  is  one  which  often  requires  consider- 
able neatness  and  dexterit3^  In  remoA'ing  the  cyst  at 
the  lower  and  inner  angle  of  the  orbit,  much  trouble  is 
frequently  exi^erienced  from  the  angular  or  the  frontal 
branch  of  the  ophthalmic  artery  being  divided,  and  the 
consequent  brisk  hemorrhage  which  follows.  It  is  sel- 
dom that  a  ligature  is  required  ;  pressure  with  the  finger 
for  a  few  minutes  will  usually  suffice  to  stop  all  the 
bleeding. 

Epicanthus. — This  term  is  applied  to  a  crescentic  fold 


370  INJURIES    OF    THE    EYELIDS.  S 

of  skin,  which  slightly  overlaps  the  inner  canthus  of  each 
e3'e.  By  increasing  the  breadth  of  the  integument  be- 
tween the  e^yes,  a  peculiar  Chinese  expression  is  given  to 
the  face,  which  is  sometimes  distasteful  to  the  i)atient  or 
his  relatives.  p]picanthus  is  congenital,  and  usually  de- 
creases as  the  child  grows  and  the  bridge  of  the  nose  is 
developed.     It  is  seldom  that  it  interferes  with  sight. 

Treotnient. — It  is  onl}-  in  extreme  epicanthus  that  any 
operative  proceeding  should  be  adopted.  In  such  cases 
a  vertical  elli[ise  of  skin  ma}^  be  excised  from  the  centre 
of  the  si)ace  between  the  eyes,  and  the  edges  of  the 
Avouud  united  with  sutures.  In  this  way  the  crescentic 
folds  of  integument  will  be  unravelled,  and  the  canthus 
of  each  eye  exposed. 

INJURIES   OF    THE    EYELIDS. 

EccHYMOSis  OF  THE  Ei'ELiDS,  or,  as  it  is  commonly 
called,  "a  black  e^'e,"  is  an  etfusion  of  blood  into  the 
cellular  tissue  of  the  lids  and  of  the  parts  surrounding 
them.  It  ma}"  be  limited  to  one  or  both  eyelids,  or  it 
nia}"  extend  to  the  cellular  tissue  of  the  face  around  the 
orbit.  The  blood  is  generall}'  absorbed  in  the  course  of 
a  week  or  ten  days,  during  which  time  the  discoloration 
gradually  fades  away,  but,  in  doing  so,  passes  through  a 
variety  of  shades  which  must  be  familiar  to  all.  It  is 
very  rare  that  anj'  suppuration  follows. 

A  black  eye  is  occasionally  complicated  with  fracture 
of  one  or  more  of  the  frontal  or  ethmoidal  cells.  This 
casualty  is  recognized  by  an  emphysematous  state  of  the 
eyelids  and  of  the  cellular  tissue  around  the  orbit.  When 
the  patient  blows  his  nose,  air  is  forced  through  the  fis- 
sured bone  into  the  neighboring  cellular  tissue.  In  no 
case  have  I  ever  seen  eni|)hyscma  of  the  lids  productive 
of  any  harm,  though  the  discomfort  it  occasions  is  always 


ECCHYMOSIS.  371 

great.  The  patient  should  be  eautioued  not  to  blow  his 
nose  for  some  days ;  the  fissured  bone  will  then  soon  be- 
come closed,  and,  if  no  fresh  air  is  forced  into  the  cellu- 
lar tissue,  that  which  is  alread3'^  there  will  rapidly  disap- 
pear. Pricking  the  integument  with  a  fine  needle  to  give 
vent  to  the  air  is  seldom  if  ever  necessary,  and  should  not 
be  resorted  to  except  in  cases  of  extreme  tension  of  the 
skin,  a  condition  which  is  not  likely  to  occur  from  a  sim- 
ple fracture  of  a  frontal  or  an  ethmoidal  cell. 

Treatment. — The  application  of  cold  immediately  after 
the  blow  will  limit  the  effusion  of  blood,  and  so  diminish 
the  extent  of  the  after  discoloration,  and  ma^-,  therefore, 
shortl}^  after  the  receipt  of  the  injur}-,  be  advantageousl}^ 
used.  This  is  best  done  by  cold  evaporating  lotions,  or 
by  applying  ice  in  an  india-rubber  bag  to  the  eye,  or  by 
a  fold  of  wet  linen  being  laid  over  the  eye,  and  frequently 
moistened  with  iced  water.  The  practice  of  ^iuncturing 
the  swollen  parts,  as  recommended  and  frequentlj-  adopted 
by  prize-fighters,  is  essentiallj^  wrong.  It  may,  and  no 
doubt  does,  afford  a  temporary  relief  to  the  swelling  when 
it  is  great,  but  it  renders  the  part  liable  to  suppuration 
and  er3'sipelas,  neither  of  which  would  have  been  antici- 
pated if  the  skin  had  not  been  cut.  A  remedy  which  has 
for  many  j-ears  received  considerable  credit,  is  a  poultice 
of  the  black  bryony  root.  It  is  "  made  b}-  mixing  some 
of  the  black  brj-ony  root  scraped  finelj'  with  a  little  crumb 
of  bread.  This  is  placed  in  a  muslin  bag  over  the  palpe- 
bral for  several  hours  together ;  and  usuall}-  it  has  an  ex- 
cellent effect  in  promoting  the  action  of  the  absorbent 
vessels."*  It  is,  however,  a  drug  which  cannot  always 
be  pi'ocured :  the  best  place  to  seek  for  it  is  from  one  of 
the  herbalists  in  Covent  Garden  Market.  The  tincture 
of  Arnica  montana  has  also  acquired  a  great  repute  for 

*  Tyrrell  ou  Diseases  of  the  Eye,  vol.  i,  p.  '20J. 


372  INJURIES   OF   THE    EYELIDS. 

the  power  it  is  supposed  to  i)ossess,  of  favoring  the  ab- 
sorption of  blood  in  cases  of  ecchymosis.  It  may  be  ap- 
plied pure  over  the  part  with  a  camel's-hair  brush,  or  it 
may  be  used  as  a  lotion  (F.  49). 

Abscess  of  the  Eyelid. — From  contusion  or  lacera- 
tion of  the  integument  of  the  lid,  acute  inflammation  and 
suppuration  of  the  subjacent  cellular  tissue  may  follow. 
The  eyelid  becomes  red,  swollen,  and  shining,  and  un- 
mistakable evidence  of  pus  is  soon  manifested.  The 
treatment  is  the  same  as  for  an  abscess  in  any  other  part 
of  the  body.  As  soon  as  it  is  clear  that  pus  has  been 
formed,  an  incision  should  be  made  to  give  vent  to  it, 
and  a  warm  poultice  should  be  afterwards  applied.  The 
only  point  which  requires  special  notice,  is  the  wa}^  in 
which  the  abscess  should  be  opened.  The  incision  should 
be  made  w^th  a  fine  sharp  knife  in  the  horizontal  direc- 
tion, and  in  a  line  with  the  orbital  fold  of  skin  just  be- 
yond the  lid.  The  cicatrix  will  be  then  a  mere  line,  and 
from  its  situation  it  will  be  scarcely  observable. 

Wounds  of  the  Eyelids  may  be  divided  into  two 
classes : 

1.  Those  which  involve  onl}^  the  skin  of  the  lid. 

2.  Those  which  have  cut  through  its  tarsal  border. 

1.  Wo^mds  which  involve  only  the  skin  of  (he  lid.,  require 
the  same  treatment  as  similar  wounds  in  any  other  part 
of  the  integument  of  the  body ;  but  from  the  delicacy'  of 
the  skin  in  this  localit^^,  and  the  importance  of  avoiding 
as  far  as  possible,  an  unseemly  scar,  more  careful  ma- 
nipulation is  needed  to  bring  the  edges  into  accurate  ai> 
position. 

2.  Wounds  which,  have  cut  through  the  tarsal  border  of 
the  lid. — In  lacerations  of  the  e3^elid  there  are  two  forms 
of  injury  to  which  its  tarsal  margin  is  exposed: 


WOUNDS    OF    THE    EYELIDS.  373 

a.  The  cartilaginous  border  of  the  lid  wvaj  be  cut  or 
torn  through  at  any  part. 

/?.  The  rent  may  pass  through  the  canaliculus,  tearing 
it  away  from  the  punctum  lachrymale,  which  may  still 
remain  intact  at  the  extremity  of  the  cartilage. 

(a.)  Where  the  cartilacjinous  border  of  the  lid  has  been 
cid.,  the  edges  of  the  wound  become  slightly  drawn  apart, 
and  an  unsightl}^  notch  is  formed.  If  the  wound  has  been 
a  clean  incised  one,  the  divided  ends  of  the  cartilage  should 
be  very  accurately'  fitted  together  and  fastened  in  situ  b}^ 
a  pin  and  twisted  suture.  The  pin  should  be  a  very  fine 
one,  such  as  is  used  by  entomologists  for  pinning  the 
smaller  insects.  It  should  be  made  to  pass  through  the 
cartilage  of  the  lid,  so  close  to  its  free  edge,  that  the  silk, 
when  twisted  on  the  pin,  will  slightly  overlay  the  tarsal 
margin.  I>y  attending  to  these  details,  accurate  union 
will  be  probably  eff"ected,  without  leaving  any  notch  or 
irregularity  of  the  border  of  the  lid.  When,  howeA'^er, 
the  edges  of  the  wound  of  the  cartilage  are  jagged  or  ir- 
regular, as  frequently  happens  when  the  lid  has  been  torn 
by  some  semi-blunt  instrument,  it  is  best  first  to  pare 
them  smooth  with  a  sharp  scalpel  before  bringing  them 
together  with  a  pin  and  twisted  suture. 

If  after  a  wound  of  the  cartilaginous  border  of  the  lid, 
no  treatment  has  been  adopted,  the  edges  of  the  gap  are 
apt  to  become  more  widely  separated,  and  occasionally  a 
certain  amount  of  eversion  is  also  produced.  The  extent 
of  the  deformit}'  will  necessarily  depend  ver}'  much  on  the 
depth  of  the  wound. 

(;?.)  When  the  canaUculua  has  been  torn  through  and  de- 
tached from  the  punctum,  a  search  should  be  first  made 
for  the  divided  end  of  the  tear  duct.  It  is  of  course  im- 
possible so  to  adjust  the  torn  parts  that  the  punctum  and 
the  canaliculus  can  again  be  made  to  communicate  with 
each  other.     If  therefore  the  open  end  of  the  divided  ca- 

32 


374  INJURIES    OF   THE    EYELIDS. 

naliculus  can  be  detected,  a  small  director  (Fig.  34,  page 
335)  should  be  passed  up  it,  and  with  a  cataract  knife  it 
should  be  slit  into  the  lachrymal  sac.  The  closed  tube 
will  thus  be  converted  into  an  open  canal,  along  which 
the  tears  will  afterwards  flow  into  their  proper  channel. 
The  torn  parts  are  then  to  be  brought  into  their  normal 
position,  and  fastened  in  situ  with  one  or  two  fine  silk 
sutures. 

RESULTS    OF  INJURIES  AND   ULCERATIONS  OF   THE    EYELIDS. 

Anchyloblepharon  is  the  union  of  the  margins  of  the 
e3'elids  to  each  other.  They  may  be  either  partiall}'  or 
completely  united.  It  is,  however,  seldom  that  the  ad- 
hesion extends  throughout  the  entire  length  of  the  lids. 
The  inner  third  of  the  two  lids  is  more  frequently  joined 
than  the  outer  or  middle  portion.  In  nearly  all  cases  of 
anchyloblepharon,  whether  partial  or  complete,  a  fistu- 
lous opening  is  left  at  the  inner  canthus,  through  which 
some  of  the  tears  find  their  way  on  to  the  face.  The 
iinion  between  the  lids  may  be  either  direct,  the  two 
edges  being  completely  adherent,  or  they  may  be  united 
by  membranous  bands  passing  from  the  one  to  the  other. 

The  causes  of  anchyloblepharon  are  lacerated  wounds, 
or  any  accident  which  produces  an  abrasion  of  the  cor- 
responding surfaces  of  the  tarsal  edges  of  the  eyelids. 

Treatment.- — When  the  union  between  the  lids  is  direct, 
and  a  fistula  exists  at  the  inner  canthus,  a  small  director 
should  be  passed  behind  the  adherent  margins,  and  out 
at  the  fistulous  orifice,  and  upon  it  the  adhesions  may  be 
severed  with  a  pair  of  scissors ;  or  if  this  cannot  be  readily 
accomplished,  the  lids  may  be  dissected  apart  with  a  shai'p 
scalpel. 

If  a  membranous  band  is  the  bond  of  union  between 
the  two  lids,  it  should  be  divided  on  a  director  passed 


SYMBLEPIIARON.  375 

beneath  it,  and  the  projecting  portions  cut  oflT  close  to  the 
margins  of  the  lids.  The  chance  of  success  following 
either  of  the  operations  depends  very  much  on  the  daily 
dressing  of  the  wound :  special  care  should  be  taken  to 
keep  the  lids  from  reuniting  during  the  process  of  cicatri- 
zation. 

This  may  be  generally  accomplished  by  daily  sepa- 
rating them,  and  anointing  the  granulating  surfaces  with 
a  little  sweet  oil. 

Symblepharon  is  an  adhesion  of  the  lids  to  the  globe. 
It  is  usuall}'  produced  by  an  injury  which  has  caused 
either  a  destruction  or  an  ulceration  of  the  opposed  con- 
junctival surfaces  of  the  lid  and  globe,  and  their  subse- 
quent union  b}"  granulation.  Lime,  mortar,  and  burns 
from  hot  metals,  or  scalds  from  hot  fluids,  are  the  most  fre- 
quent causes  of  s3'mblepharon,  but  it  may  be  produced  by 
any  agent  which  either  destro^'s  or  abrades  the  corre- 
sponding parts  of  the  lids  and  globe.  Most  of  the  very 
severe  cases  of  symblepharon  which  have  come  under  my 
notice  have  been  due  to  lime.  If  the  injur}'  it  has  in- 
flicted is  severe,  it  is  absolutely  impossible  to  prevent  the 
union  of  the  lids  to  the  globe.  All  endeavors  to  keep  the 
opposed  granulating  surfaces  apart  will  fail.  The  con- 
traction which  goes  on  during  the  process  of  cicatrization 
draws  the  lid  and  globe  into  close  apposition,  and  direct 
union  will  ensue  in  spite  of  all  eflbrts  to  stop  it. 

Symblepharon  is  said  to  be  complete  wdien  the  entire 
inner  surface  of  one  lid  is  adherent  to  the.  globe,  and 
jwrtial  when  the  adliesion  is  limited  to  only  a  part  of  the 
opposed  surfaces.  Both  eyelids  may  be  often  seen  par- 
tially' attached  to  the  globe,  or  the  lower  lid  maj'  be  com- 
pletely united  to  it ;  but  it  is  exceptional  to  meet  with 
complete  symblepharon  of  both  the  upper  and  loAver  lids 


376  INJURIES    OF   THE    EYELIDS. 

of  the  same  eye.     The  lower  eyelid  is  much  more   fre- 
(pieiith'  att'ected  hy  symLlepharon  than  the  ujjper. 
Two  forms  of  symblepharon  may  be  recognized  : 

1.  Membranous  bands  or  frena  passing  between  the  lids 
and  the  globe. 

2.  Direct  and  close  adhesions  between  the  opposed  sur- 
faces of  the  eye  and  lids. 

1.  Membranous  Bands  heticeen  the  Lids  and  Globe. — 
This  is  the  simplest  and  most  remediable  kind  of  symble- 
pharon. It  is  due  to  a  less  extensive  and  more  super- 
ficial injur}^  than  that  which  produces  the  second  form  ; 
generally  to  some  limited  ulceration  or  abrasion  of  the 
corresponding  parts  of  the  eye  and  lids.  During  the 
hea^ling  process  the  granulations  of  the  opposed  surfaces 
become  united,  but  the  constant  pull  which  is  exerted 
ujDOU  them  by  the  movements  of  the  globe  will  often  so 
stretch  the  adhesions  that  they  will  become  elongated  into 
membranous  bands. 

2.  Direct  and  close  Adhesions  between  the  oj^posed  Sur- 
faces of  the  Eye  and  Lids. — These  are  caused  by  an  ab- 
solute destruction  of  corresponding  portions  of  the  con- 
junctiva of  the  eye  and  lid.  Deep  ulceration  or  slough- 
ing follows  the  injury,  and  opposed  granulating  surfaces 
are  left,  which  ultimately  become  firmly  adherent  and 
blended  with  each  other.  During  the  cicatrization,  the 
contraction  of  the  surrounding  conjunctiva  draws  the  lid 
and  globe  into  such  close  contact,  that  the  movements  of 
the  eye  cannot  stretch  the  bond  of  union,  and  the  lid  and 
globe  remain  forever  afterwards  lirndj'  bound  together. 

Treatment. — All  oi)erations  for  the  cure  of  symblepha- 
ron are  as  a  rule  very  unsatisfactory  :  in  the  severe  cases  « 
they  generally  fail  to  effect  any  good  ;  and  in  the  milder 
ones,  the  relief  which  is  afforded  is  comparative.  It  is 
only  in  the  slight  cases  that  jwsitive  good  will  be  found 
to  follow  surgical  treatment, — those  in  which  small  mem- 


SYMBLEPHARON.  377 

branons  Lands  ov  tags  of  adhesion  pass  between  the  e_ye- 
lids  and  the  globe.  When  these  are  insnhited,  so  that  a 
l)robe  can  be  passed  beneath  them,  and  the  oculo-i)al- 
pebral  fohl  of  conjunctiva  still  exists  entire,  much  benefit 
will  be  derived  from  an  operation. 

There  are  tAvo  wa^'s  in  which  these  narrow  mem])ranous 
bands  may  be  treated. 

'X.  They  may  be  simply  divided  by  a  scalpel  or  a  pair 
of  fine  scissors  ;  and  b^'  daily  passing  the  end  of  a  probe 
dipped  in  a  little  sweet  oil  between  their  cut  ends,  re- 
union may  generally  be  prevented.  This  mode  of  treat- 
ment is,  however,  only  applicable  to  the  very  mild  cases, 
where  a  simple  tag  of  adhesion  ties  the  lid  to  the  globe. 

/?.  If  the  bands  are  small,  they  may  be  first  cut  off 
close  to  the  globe,  and  the  edges  of  the  wound  which  is 
thus  made  in  the  conjunctiva  maybe  drawn  together  and 
united  b}'  one  or  two  fine  stitches.  The  other  extremities 
of  the  bands  are  then  to  be  severed  from  their  attachment 
to  the  lid.  As  in  the  first  operation,  careful  daily  dressing 
will  be  required  to  prevent  a  rej  unction  of  the  cut  sur- 
faces, for  unless  the  wound  in  the  conjunctiva  closes  by 
immediate  union,  which  it  may  fail  to  do,  the  tendency  to 
a  return  of  the  symblepharon  is  very  great. 

In  those  cases  of  symblepharon  where  there  are  direct 
and  clone  adhesions  bettveen  the  eye  and  the  lids,  many 
different  plans  of  treatment  have  been  tried,  but  most  of 
them  without  much  success.  It  is  onl}^  where  the  extent 
of  the  conjunctival  surfaces  involved  is  small,  that  even 
amelioration  can  be  hoped  for.  The  lid  may  be  generally 
easily  separated  from  its  union  with  the  globe  by  a  care- 
ful dissection,  but  we  have  no  means  at  our  command  by 
which  we  can  prevent  their  again  uniting.  Plates  of  metal 
and  glass  shields  have  been  interposed  between  the  gran- 
ulating surfaces,  but  with  very  indifferent  success.    The}' 

'.V2* 


378  INJURIES    OF    THE    EYELIDS. 

have  been  generally  extrnded  dui'ing  the  contraction 
which  accompanies  cicatrization. 

Mr.  T.  Pridgin  Teale,  of  Leeds,  has  suggested  a  plastic 
operation  in  cases  of  sj'inblepharon,  which  he  speaks  of 
very  favorably.  He  first  described  it  in  the  Koyal  Lon- 
don Oplithahnic  Hospital  Reports,  vol.  iii,  p.  253,  in  which 
he  has  cited  cases  which  have  been  materiall}'  benefited 
b}'  it.  In  a  short  note  which  he  has  kindly  given  me,  he 
thns  describes  the  oj^eration  :  •'  The  adherent  lid  having 
been  dissected  off"  the  eyeball  so  as  to  leave  the  globe  per- 
fectly free  in  its  movements,  one,  or,  if  possible,  two  flaps 
of  conjunctiva  are  dissected  from  the  sound  part  of  the 
e^-eball,  and  transplanted  into  the  gap.  If  an}-  portion  of 
the  adherent  lid  is  united  to  the  cornea,  the  separation  of 
the  lid  is  commenced  at  the  margin  of  the  cornea,  leav- 
ing the  apex  of  the  lid  still  in  situ  as  an  opaque  spot  on 
the  cornea."  There  are,  however,  very  many  cases  of 
s^'mblepharon  where  no  operation  should  be  attempted. 
The  extent  of  the  adhesions  may  be  so  great  that  it  would 
be  worse  than  useless  to  endeavor  to  divide  them. 

Anchylohlepharon  and  symhlepharon  are  often  asso- 
ciated ;  indeed,  Avith  the  nnion  of  the  margins  of  the  lids 
it  is  very  general  to  find  also  some  adhesion  between  the 
conjunctival  surfaces  of  the  lid  and  globe.  It  is,  however, 
rare  to  find  in  one  eye  a  complete  union  of  the  globe  to 
the  lids,  and  of  the  lids  to  each  other. 


ABSCESS    OF   THE   ORBIT.  379 


CHAPTER  XL 


DISEASES    OP    THE    ORBIT. 


Abscess  of  the  Orbit  may  be  caused  by  blows  on  the 
e3'e,  by  penetrating  wounds  of  the  orbit,  or  by  any  vio- 
lence producing  fracture  of  its  bony  walls,  by  the  lodge- 
ment of  a  foreign  bod}'  in  the  orbital  cellular  tissue,  or 
occasionally  by  the  extension  backwards  of  a  suppurative 
inflammation  of  the  lids,  or  of  the  tissues  in  immediate 
contiguity  with  the  eye,  no  matter  how  induced.  Inflam- 
mation of  the  cellular  tissue  of  the  orbit  (orbital  cellu- 
litis), brought  on  from  any  cause,  may  terminate  in  ab- 
scess of  the  orbit.  Caries,  necrosis,  or  orbital  periostitis 
may  likewise  lead  to  orbital  abscess. 

Abscess  of  the  orbit  may  be  either  acute  or  chronic.  In 
the  former  the  inflammatory  symptoms  generally  rapidly 
follow  the  injury ;  they  are  sharp  and  quick  in  their  pro- 
gress, pus  is  soon  formed,  and  independently  of  the  his- 
tory of  the  case,  iinmistakable  evidence  of  its  presence  is 
artbrded  by  the  pain,  heat,  redness,  and  swelling.  Occa- 
sionall^y,  however,  there  is  a  variable  interval  of  a  week  or 
more  of  perfect  quiet  and  freedom  from  pain  after  the  in- 
jury before  an}'  premonitory  symptoms  show  themselves, 
but  when  once  started  their  course  is  equally  acute  and 
rapid. 

Symjotoms  of  Acute  Abscess  of  the  Orbit. — Deep-seated 
pain  in  the  orbit  extending  around  the  brow,  worse  at  one 
time,  better  at  another,  but  never  absent,  and  steadily  in- 
creasing in  severity.  Any  pressure  on  the  eye,  or  even 
moving  it,  aggravates  the  pain.    The  ej^elids  become  red, 


380  DISEASES    OF    THE    ORBIT. 

shining,  and  rrdematons  ;  and  tlie  conjnnctiva  of  the  lids 
and  glol)e  vascular,  swollen,  and  chcmosed.  The  eye  is 
now  observed  to  protrude  slight!}'  be3ond  the  level  of  the 
other,  and  this  protrusion  increases  as  the  disease  ad- 
vances and  the  pus  makes  its  wa}'  to  the  surface.  The 
dis[)lacemeut  is  usually  not  directl}'  forwards,  hut  more 
or  less  downwards  and  outwards,  as  it  is  dependent  on 
the  situation  of  the  abscess  within  the  orbit  and  the  part 
of  the  eye  on  which  it  presses.  AVith  the  increasing  pro- 
trusion of  the  globe,  the  sight  becomes  more  or  less  im- 
paired from  the  strain  which  is  being  exerted  on  the  optic 
nerve.  The  orbital  fold  of  skin  above  the  lid  becomes 
obliterated,  and  the  upper  lid  so  swollen  and  stretched  iu 
front  of  the  bulging  eye  that  it  cannot  be  raised  b}'  the 
patient.  Over  the  most  prominent  j^art  of  the  swelling  a 
careful  examination  with  the  fingers  will  detect  fluctua- 
tion. The  most  usual  spot  for  the  matter  to  point  is 
rather  to  the  inner  side  of  the  interval  between  the  supra- 
orbital ridge  of  the  orbit  and  the  upper  border  of  the 
globe.  Occasionally  the  suppuration  may  be  more  or  less 
confined  to  one  or  other  side  of  the  orbit,  and  this  will  in 
a  great  measure  determine  the  site  at  which  the  pus  will 
endeavor  to  make  its  exit ;  either  the  inner,  outer,  or 
lower  side  of  the  eye  may  })e  the  part  selected.  When 
the  abscess  is  a  small  and  limited  one,  there  may  be  little 
or  no  displacement  of  the  eye. 

"NN'ith  all  these  local  symptoms  there  is  always  consider- 
able constitutional  disturbance.  The  skin  is  hot  and  dr^' , 
the  patient  has  occasional  rigors,  he  is  restless,  and  his 
sleep  is  broken  from  pain. 

In  chronic  abscess  of  the  orbit  the  symptoms  are  often 
masked  by  the  yery  slowness  with  which  they  develop 
themselves,  and  by  the  absence  of  funy  severe  pain.  It 
frequently  happens  that  the  patient  does  not  even  seek 
advice  until  an  increasing   protrusion  of  the  eye  and 


ABSCESS    OF   THE    ORBIT.  381 

a  somewhat  corresponding  diminution  in  vision  excite 
alarm. 

Clironic  abscess  of  the  orbit  is  often  most  difficult  to 
diagnose,  and  may  easily  be  confounded  with  a  medullary, 
or  recurrent  fibroid,  or  some  soft  orbital  tumor,  the  elas- 
ticity of  which  closely  resembles  fluctuation.  The  exciting 
cause  of  the  abscess  may  have  been  an  injury  inflicted  at 
some  distant  period,  which  has  been  forgotten,  and  from 
which  the  patient  thought  he  had  completely  recovered; 
or  the  slow  progress  of  the  disease,  and  the  comparative 
and  in  many  cases  complete  absence  of  pain  during  its 
early  stages,  may  make  it  difficult,  if  not  impossible,  for 
the  patient  to  give  a  correct  account  of  how  or  when  it 
commenced.  When  doubt  exists  as  to  the  true  nature  of 
the  case,  an  exploratory  incision  should  be  made  into  the 
tumor,  and  the  surgeon  should  be  prepared  to  act  at 
once  on  the  information  it  will  aflbrd  him.  If  it  is  an 
abscess,  the  incision  should  be  enlarged  sufficiently  to  give 
a  free  exit  to  the  pus ;  but  if,  on  the  other  hand,  it  should 
prove  an  orbital  tumor,  it  should,  if  practicable,  be  re- 
moved without  any  further  delay. 

Treatment  of  Al)scess  of  the  Orbit. — As  soon  as  it  is  clear 
that  pus  has  formed,  and  that  the  protrusion  of  the  eye, 
if  there  is  an}-,  is  due  to  its  presence  in  the  orbit,  a  free 
opening  should  be  made  for  its  escape.  The  site  for 
making  the  incision  should  be  that  spot  where  there  is 
the  most  distinct  swelling  and  fluctuation,  and  where  the 
pus  has  a  tendency  to  point.  After  a  free  vent  has  been 
given  to  the  pus  within  the  orbit,  a  warm  linseed-meal 
poultice  should  be  applied,  and  care  should  be  taken  that 
the  wound  is  kept  open  by  examining  it  dail}',  and,  if 
necessary,  by  passing  a  probe  along  the  course  of  the  in- 
cision to  prevent  the  cut  edges  from  uniting.  It  not  nn- 
frequentl}'  happens,  after  an  abscess  of  the  orbit,  that  the 
wound  from  the  incision  only  partially  closes,  and  a  long 


382  DISEASES    OF   THE    ORBIT. 

sinus  remains  from  which  a  slight  pnvulent  diseliarge 
continues  to  drain.  When  this  is  tlie  case,  and  when  no 
fragment  of  necrosed  bone  can  be  detected  by  a  probe 
to  account  for  it,  the  use  of  a  stimulating  injection,  such 
as  zinci  sulphat.  gr.  2  ad  aqute  5  1,  thrown  into  the  sinus 
with  a  glass  S3'ringe  twice  a  day,  will  often  prove  of  great 
benefit.  If,  however,  a  portion  of  dead  bone  is  felt  with 
the  probe,  time  must  be  given  to  allow  of  its  becoming 
detached,  or  at  least  partially  loosened  from  the  living 
structure ;  and  then,  after  enlarging  the  orifice  of  the 
sinus,  it  may  be  removed  with  a  pair  of  sequestrum  for- 
ceps, first  using,  if  necessar}^,  a  gouge,  or  an  elevator,  or 
a  pair  of  fine-cutting  bone  forceps,  to  separate  an}^  por- 
tion of  bone  which  may  be  holding  it. 

Fractures  of  the  Bones  of  the  Orbit  may  be  caused 
by  blows  on  the  head,  or  by  the  impaction  within  its 
cavity  of  a  large  foreign  bod}^,  one  extremit}^  of  which  has 
passed  through  the  orbital  walls  into  the  antrum  or  the 
posterior  nares.  When  the  fracture  extends  into  the 
frontal  or  ethmoidal  cells,  there  is  generally  emphysema 
of  the  cellular  tissue  of  the  lids  and  the  surrounding 
parts.  This  arises  from  the  patient  forcibh'  driving  the 
air  through  the  broken  cells  when  he  blows  his  nose. 
Fracture  of  the  orbit  is  often  associated  with  fracture  of 
other  portions  of  the  skull,  and  in  such  cases  it  frequentl}^ 
happens  that  the  contusion  or  laceration  of  the  brain 
produced  b}'  the  blow  is  sufficient  to  cause  death,  inde- 
pendently of  the  injury  which  the  cranial  bones  have  sus- 
tained. 

There  is,  however,  one  form  of  fracture  Avhich  is  con- 
fined to  the  Avails  of  the  orbit,  and  which  is  very  fatal.  It 
is*caused  by  direct  violence,  and  is  commonly  produced 
b}"  a  forcible  tlu-ust  in  the  e^-e  with  a  shar})  or  semi- 
blunt  pointed  instrument,  such  as  the  points  of  a  pair  of 


FRACTURES    OF   THE    ORBIT.  383 

scissors,  the  end  of  an  umbrella  or  a  foil,  or  b3'  the  stem  of 
a  long  tobacco-pipe.  The  orbit  is  penetrated,  and  the  end 
of  the  stick,  or  whatever  it  may  be,  is  thrust  against  its 
roof  or  the  upper  part  of  its  inner  wall,  which  it  in  some 
cases  fractures,  whilst  in  others  it  breaks  its  vfa.y  through 
the  bone  and  penetrates  the  substance  of  the  brain.  From 
such  an  injury  the  patient  seldom  recovers  :  even  when 
the  bones  are  broken,  but  not  penetrated,  the  sharp 
splinters  usually  create  such  irritation  of  the  brain  and 
its  membranes  that  a  fatal  result  ensues.  One  peculiarity 
of  this  accident  is,  that  its  severe  nature  is  apt  to  be  often 
overlooked ;  the  exteiuial  wound  ma}"  be  small,  the  imme- 
diate symptoms  may  be  trifling,  and  the  patient,  if  a  me- 
chanic, may  be  able  to  continue  his  work  some  hours,  or 
it  ma}'  be  for  two  or  three  days,  before  his  condition 
obliges  him  to  desist.  Symptoms  of  inflammation  and  sup- 
puration may  then  come  on,  coupled  Avitli  those  of  cerebral 
or  meningeal  irritation  ;  the  patient  may  pass  rapidl}-  from 
slight  delirium  to  complete  coma,  and  die  in  a  period 
varying  from  a  few  days  to  two  or  three  weeks. 

Treatment  of  Fractures  of  the  Orbit Fracture  of  the 

orbit  requires  the  same  treatment  as  fracture  of  any  other 
portion  of  the  bones  of  the  skull,  with  the  exception  that 
even  if  there  is  reason  to  believe  that  a  fragment  of  one 
of  the  orbital  bones  may  be  pressing  injuriouslj^  on  the 
brain,  no  operation  can  be  attempted  to  dislodge  it.  Ab- 
solute rest,  both  mental  and  bodily,  should  be  enjoined  in 
all  cases  where  a  fracture  of  the  orbit  is  suspected.  The 
patient  should  be  kept  in  bed,  and  cold  water  dressings, 
or  an  india-rubber  bag  of  ice  should  be  laid  over  the  eye 
and  brow  of  the  injured  side;  and  the  bowels  should  be 
freelj'  acted  on  by  a  brisk  purgative.  All  stimulants 
should  be  forbidden,  and  a  limited  diet  should  be  ordered. 
If  there  is  much  pain  in  the  head,  six  or  eight  leeches 
should  be  applied  to  the  temple,  and  these  may  be  re- 


384  DISEASES    OF   THE    ORBIT. 

peated  iu  twenty-lbiir  hours  if  the  symptoms  become  more 
urgent. 

Foreign  Bodies  in  the  Okbit, — The  lodgement  of  a 
foreign  body  within  the  orbit  is  one  of  the  most  danger- 
ous accidents  which  can  be  met  witli  in  ophthahnic  prac- 
tice, as  it  not  onl}^  always  involves  a  serious  risk  to  the 
eye,  but  it  places  even  the  life  of  the  patient  in  consider- 
able jeopardy,  and  in  some  instances  has  caused  death. 
It  may  prove  hurtful  to  the  patient  both  b}'  the  immediate 
and  secondarj^  effects  it  is  liable  to  produce. 

The  immediate  effects  which  may  arise  from  the  lodge- 
ment of  a  foreign  body  in  the  orbit  are : 

1.  In  its  passage  into  the  orl)it,  it  may  either  injure  the 
parts  within  the  e^'e,  or  rupture  its  external  coats. 

2.  Although  the  eye  itself  may  escape  injury,  the  optic 
nerve  may  be  wounded,  and  absolute  blindness  follow. 

3.  It  may  injure  the  walls  of  the  orbit,  either  by  pene- 
trating them  or  by  causing  fracture. 

The  secondary  effects  which  a  foreign  bod}'  within  the 
orbit  may  excite  are  : 

a.  If  a  foreign  body  has  escaped  observation,  and  has 
been  allowed  to  remain  buried  in  the  orbit,  it  ma}'  excite 
orbital  cellulitis  and  abscess.  This  may  lead  on  to  a 
general  inflammation  of  the  globe,  which  maj'  end  iu  great 
impairment  of  vision,  or  in  complete  destruction  of  the 
e^-e  from  suppuration. 

/3.  As  a  consequence  of  the  orbital  inflammation,  a  por- 
tion of  the  bones  of  the  orbit  may  become  necrosed. 

y.  The  inflammation  ma}^  extend  backwards  along  the 
periosteum  lining  the  orbital  walls  to  the  membranes  of 
the  brain,  and  destroy  the  patient  by  meningitis,  tetanic 
convulsions,  or  abscess  of  the  brain. 

Treatment. — Whenever  it  can  be  clearly  established 
that  a  foreign  body  is  impacted  iu  the  orbit,  the  treat- 


FOREIGN    BODIES    IN    THE    ORBIT.  385 

meiit  is  to  endeavor  to  remove  it  as  soon  as  possible.  To 
this  rule,  however,  there  are  exceptions ;  and  these  are, 
when  the  foreign  body  is  a  small  sliot,  or  a  fine  scale  of 
metal  which  may  have  flown  off  from  a  rivet  and  passed 
into  the  orbit  without  injury  to  the  eye.  The  almost  im- 
possibility of  finding  a  small  object  in  a  mass  of  cellular 
tissue  forbids  the  attempt  to  hunt  after  it.  If  it  can  be 
easil}^  felt  with  a  probe  introduced  through  the  wound,  it 
should  be  removed,  but  no  lengthened  exploratory  opera- 
tion should  be  attempted  with  the  view  of  seeking  for  it. 
Such  a  proceeding  would  probably  excite  more  irritation 
than  would  arise  from  the  presence  of  a  small  metallic 
bod}^  in  the  orbit.  It  should  also  be  remembered  that 
small  masses  of  metal  may  be  often  imbedded  in  the  cel- 
lular tissue  of  any  part  of  the  body  without  producing  a 
symptom  of  irritation,  and  that  they  may  remain  there 
for  many  years  without  causing  any  disturbance. 

Having  ascertained  by  a  careful  investigation  tl'at  a 
foreign  bod}^  is  in  all  probability  imbedded  in  the  orbit, 
the  following  operation  for  its  removal  may  be  performed. 

The  outer  canthus  should  be  freely  divided,  either  by 
a  pair  of  scissors  or  with  a  scalpel,  to  allow  of  the  upper 
lid  being  completely  turned  up,  or  the  lower  one  drawn 
down,  according  to  the  locality  in  which  the  foreign  body 
is  lodged.  If  it  has  entered  the  orbit  above  the  globe,  the 
upper  lid  is  to  be  I'aised,  and  the  reflection  of  conjunctiva 
between  the  lid  and  the  e3'e  is  to  be  divided  over  the  spot 
where  the  foreign  body  is  suspected  to  be  lying.  A  probe 
or  the  little  finger  may  then  be  passed  through  the  wound 
into  the  orbit  by  the  side  of  the  e^-e,  and  having  felt  the 
object,  it  may  be  seized  and  drawn  out  with  a  pair  of 
sequestrum  forceps.  When  tlie  foreign  body  has  entered 
the  orbit  below  the  globe,  the  lower  lid  must  be  drawn 
down,  and  the  lower  oculo-palpebral  fold  of  conjunctiva 

33 


386  DISEASES    OF    THE    ORBIT. 

must  be  divided,  but  tlie  remaining  steps  of  tlie  operation 
are  the  same  as  tliose  already  described. 

If  tlie  foreign  body  has  become  entangled  with  one  of 
the  recti  muscles,  or  from  any  other  cause  one  of  them 
should  interfere  with  its  eas}^  withdrawal  from  the  orbit, 
it  is  better  at  once  to  divide  the  muscle  with  a  pair  of 
scissors  as  close  as  possible  to  the  globe,  rather  than 
to  use  any  force  to  overcome  the  resistance  it  may  be 
causing. 

Penetrating  Wounds  of  the  Orbit  are  alwa3-s  serious. 
The  exact  injury  which  has  been  inflicted  can  often  be 
only  surmised,  and  time  is  required  for  the  manifestation 
of  s^'mptoms,  before  either  a  correct  diagnosis  or  prog- 
nosis of  the  case  can  be  formed.  The  instrument  which 
has  caused  the  accident  should  be  examined,  to  see  if  any 
fragment  of  it  has  been  broken  off  and  left  behind  in  the 
orbital  cellular  tissue,  and  the  direction  in  which  it  pene- 
trated the  orbit  should  be  noted.  The  patient  should  be 
kept  under  careful  supervision  for  some  days,  so  as  to 
enable  the  surgeon  to  treat  from  the  onset  any  unfavor- 
able s^'mptoms  that  may  arise.  Even  when  no  injury  has 
been  inflicted  to  the  bones  of  the  orbit,  orbital  cellulitis 
and  abscess  are  very  apt  to  ensue. 

Periostitis  of  the  Orbit  is  usually  chronic,  but  small 
portions  of  the  orbital  periosteum  are  occasionally  acutely 
inflamed.  Acute  diffuse  periostitis  rarely  if  ever  affects 
the  orbit. 

Chronic  periostitis  of  the  orbit  is  nearly  alwa.ys  syphi- 
litic. It  iisually  leads  to  the  formation  of  nodes,  or  the 
effusion  of  l^mph  beneath  the  periosteum.  The  most  fre- 
quent position  of  the  nodes,  for  which  the  ophthalmic 
surgeon  is  consulted,  is  on  the  frontal  bone  just  over  the 
brow;  but  they  sometimes  occur  within  the  orbit  and  give 


PERIOSTITIS    OF    THE    ORBIT.  387 

rise  to  grave  symptoms.  The  nodes  of  the  flat  bones  usu- 
ally dirter  in  their  progress  from  those  which  are  so  com- 
monly seen  on  the  tibia  and  other  long  bones ;  for  whereas 
in  the  latter  they  frequently  ossify  and  form  bony  projec- 
tions; in  the  former  (the  flat  bones),  and  especially  in 
those  of  the  skull,  the  effused  13'mph  often  softens,  and 
pus  is  formed  beneath  the  periosteum,  and  a  portion  of 
the  subjacent  bone  eitlier  exfoliates  or  becomes  carious. 

Si/mpfoins. — Dull  aching  pain,  which  is  worse  at  nights, 
when  it  is  usually  sufficiently  severe  to  prevent  sleep  ; 
swelling  of  the  part,  evident  to  the  sight  and  the  touch 
when  it  occurs  over  the  superciliary  ridge :  but  when  the 
periostitis  is  within  the  orbit,  the  swelling  is  indicated  by 
the  impaired  motions  of  the  eyeball ;  or  b^'  paral^'sis  of 
one  or  more  of  its  muscles,  if  the  node  is  in  a  locality 
where  the  ocular  nerves  can  be  affected  by  it ;  and  if  the 
swelling  is  large,  there  is  some  protrusion  or  displace- 
ment of  the  e3'e.  If  the  node  within  the  orbit  should 
soften,  and  pus  be  formed,  all  the  symptoms  which  char- 
acterize orbital  abscess  will  gradually  develop  themselves ; 
and  after  the  matter  has  been  evacuated,  a  chronic  dis- 
charge will  probably  continue  until  some  portion  of  the 
orbital  bones  has  exfoliated. 

Treatment In  chronic  orbital  periostitis  there  is  gen- 

eralh'  a  past  history  of  syphilis,  possibly  dated  back  many 
3'ears ;  but  when  this  cannot  be  obtained,  the  surgeon 
must  use  his  own  judgment  as  to  the  patient's  veracitj', 
and  treat  the  case  accordingly.  The  most  useful  medi- 
cine is  the  iodide  of  potassium,  which  should  be  given  in 
the  first  instance,  in  doses  of  from  gr.  3  to  gr.  5  three 
times  a  day ;  but  if  these  fail  to  do  good,  they  may  be  in- 
creased up  to  gr.  8  or  gr.  10.  To  relieve  pain  and  favor 
the  absorj:)tion  of  the  effused  lymph,  the  unguent,  hydrarg. 
cum  belladonna  (F.  90)  may  be  rubbed  into  the  brow,  and 
left  on  during  the  day.     When  the  paiu  is  very  severe,  a 


388  DISEASES    OF   THE    ORBIT. 

subcutaneous  injection  of  gr.  ^  to  gr.  ^  of  the  acetate  of 
morphia  (F.  24),  or  gr.  5  of  the  pil.  saponis  cum  opio, 
may  be  given  at  night.  If  these  remedies  fail,  a  mixture 
with  iodide  of  potassium  and  perchloride  of  mercury 
(F.  78)  may  be  ordered.  If  the  node  witliin  the  orbit 
soften,  and  pus  be  formed,  an  opening  should  be  made 
to  give  vent  to  it;  and  if  a  chronic  discharge  continue, 
and  this  be  found  dependent  on  a  portion  of  dead  bone 
not  yet  exfoliated,  the  sinus  should  be  syringed  out  twice 
a  day  with  a  little  tepid  water,  or  with  a  very  weak  solu- 
tion of  carbolic  acid,  about  tijj  3  ad  aquae  ^  1.  As  soon 
as  the  probe  detects  that  the  bone  is  loosened,  the  sinus 
should  be  enlarged,  and  the  exfoliated  piece  be  removed 
with  a  pair  of  forceps. 

Acute  Perioatitis  of  the  Orbit  is  an  acute  inflammation 
of  a  portion  of  the  orbital  periosteum  which  may  have 
been  detached  from  the  bone  or  otherwise  injured  by 
some  penetrating  wound  of  the  orbit,  or  may  have  be- 
come secondarily  affected  during  an  attack  of  orbital 
cellulitis.  It  is  accompanied  by  severe  pain  and  by  the 
formation  of  pus,  which  will  give  rise  to  all  the  symp- 
toms described  in  the  section  Abscess  of  the  Orbit. 
The  piece  of  bone  which  is  subjacent  to  the  inflamed  peri- 
osteum usually  perishes,  and  a  discharge  of  fetid  pus  con- 
tinues to  drain  through  the  external  wound  by  which  the 
matter  was  first  evacuated,  until  the  dead  bone  is  detached 
from  the  living  and  removed  from  the  orbit. 

Acute  Diffuse  Periostitis  rarely,  if  ever,  attacks  the 
orbit ;  indeed,  I  do  not  remember  having  seen  such  a 
case,  if,  b}'  the  name,  is  meant  a  diffuse  inflammation 
analogous  to  that  which  occasionally^  affects  the  perios- 
teum of  long  bones.  A  good  account  of  this  aflection 
is  given  in  Holmes's  "  System  of  Surger}-,"  in  the  article 
"  Diseases  of  Bones,"  vol.  iii,  page  (124,  written  b3'  him- 
self.    He  says :  "  The  pathology  of  the  disease  appears 


NECROSIS    AND    CARIES    OF    THE    ORBIT.  389 

to  consist  in  the  partial  separation  of  tlie  periosteum 
from  the  bone,  by  efTusion  on  the  surface  of  the  latter  of 
l3'mph  or  other  products,  soon  giving  place  to  a  copious 
formation  of  pus,  which  spreads  along  the  whole  bone, 
and  dissects  away  the  periosteum  from  it,  often  from  one 
end  of  the  bone  to  the  other."  And  further  on  he  states 
that  "  the  whole  diaphysis  usually  perishes,  leaving  the 
articular  ends  unaffected,  and,  tlierefore,  not  involving 
the  neighboring  joint."  The  disease  is  generally  ascribed 
to  an  injur}' ;  it  is  very  rapid  in  its  progress,  and  often 
terminates  in  death  by  pyaemia.  The  patients  usually  af- 
fected, are  the  joung  and  strumous.  I  have  seen  several 
examples  of  this  formidable  disease  in  the  long  bones, 
general!}'  the  femur ;  but  it  has  never  occurred  to  me  to 
see  anything  approaching  to  it  in  the  orbit. 

Treatment  of  Acute  Periostitis  of  the  Orbit. — When  it 
is  traumatic,  or  is  due  to  orbital  cellulitis,  the  application 
of  linseed-meal  poultices  and  warm  fomentations  give  the 
most  relief  during  the  acute  suppurative  period.  As  soon 
as  there  is  reasonable  evidence  that  pus  has  formed,  an 
incision  should  be  made  into  the  orbit  to  give  exit  to  it. 
For  the  chronic  discharge  kept  up  by  the  presence  of  dis- 
eased bone,  see  Treatment  op  Chronic  Periostitis  of 
Orbit,  page  387.  The  patient  should  be  ordered  tonics, 
stimulants,  and  a  lilteral  diet.  The  disease  is  ver}'  de- 
pressing, and  it  is  not  specific  ;  iodide  of  potassium  and 
mercurials  are,  therefore,  contraindicated. 

Necrosis  and  Caries  of  the  Orbit. — Xccrosis  of  a 
portion  of  one  or  more  of  the  orbital  bones  generall}' 
arises  from  periostitis  induced  by  an  injury,  or, by  an 
acute  orbital  abscess  ;  whereas,  caries  is  usually  produced 
b}'  some  constitutional  taint,  such  as  syphilis  or  struma. 
In  the  two  preceding  sections,  it  is  shown  that  both  caries 
and  necrosis  may  follow  inllammation  of  the  periosteum 

33* 


390  DISEASES    OF   THE    ORBIT. 

of  the  orbit.  Caries  of  the  malar  bone  is,  however,  more 
frequent  than  caries  of  the  orbit,  and  it  is  a  form  of  the 
disease  which  the  ophthalmic  surgeon  is  frequently  called 
upon  to  treat,  as  it  is  the  cause  of  a  very  troublesome 
ectropion. 

Treatment. — For  necrosis,  no  permanent  cure  can  be 
effected  until  the  piece  of  dead  bone  has  been  remoA'ed. 
Time  should  be  given  to  allow  of  its  being  loosened  from 
the  living  structures,  and  then  guided  by  a  probe  passed 
through  the  sinus,  by  which  the  discharge  escapes,  an 
incision  should  be  made  down  to  the  necrosed  bone, 
which  should  be  removed  with  a  pair  of  fine  bone  forceps. 
For  caries  the  treatment  is  different.  True  caries  is 
strictl}"  ulceration  of  bone,  or,  in  other  words,  a  degener- 
ation of  the  bone  particles,  which  are  thrown  off,  and  may 
often  be  detected  in  the  discharge.  As  in  ulcers  of  the 
skin,  the  object  of  the  treatment  is  to  restore  health}^  ac- 
tion, and  thus  produce  cicatrization.  This  ma}'  be  aimed 
at  by  constitutional  and  local  ti'catment.  Where  there  is 
a  S3'philitic  taint,  the  iodide  of  potassium  with  iron  (F.  73), 
or  the  iodide  and  bromide  of  potassium  combined  (F.  77), 
or  other  anti-syphilitic  remedies  may  be  given  ;  but  when 
the  disease  maj^  be  attributed  to  a  strumous  diathesis, 
cod-liver  oil,  the  s^^rup  of  the  iodide  or  hypophosphite  of 
iron  will  generally  do  good,  and  especiall}^  if  at  the  same 
time  the  patient  can  obtain  sea  air  and  a  nutritious  diet, 
of  which  milk  and  eggs  form  a  part. 

The  best  local  ai)plications  are  the  lotio  rubra  (F.  51), 
a  lotion  of  carbolic  acid  (F.  45),  or  of  chloride  of  zinc, 
gr.  1  ad  aquae  %  1.  They  should  be  injected  up  the  sinus 
b}'  a  glass  S3'ringe  twice  a  day ;  and  if  one  lotion  causes 
too  much  irritation,  another  should  be  substituted.  If, 
however,  all  these  remedies  fail,  a  cure  may  be  often  ac- 
complished 1>3'  making  an  incision  down  to  the  carious 
bone,  and  gouging  away  the  soft  and  diseased  structure. 


ANEURISM    OF   THE    ORBIT.  391 


ANEURISMS   OF   THE    ORBIT. 

There  are  three  forms  of  aueurism  which  may  be  met 
with  in  tlie  orbit : 

1.  The  true  and  the  false  aneurism. 

2.  The  diffuse  or  consecutive  aneurism. 

3.  Aneurism  by  anastomosis. 

1.  The  T7'ue  and  False  Aneurism. — By  the  term  true 
is  understood  a  simple  circumscribed  dilatation  of  the 
three  coats  of  the  arter^^;  whilst  the  iiilQ  fahe  is  improp- 
Qvly  applied  to  the  n^ost  usual  form  of  aneurism,  in  which 
the  middle  and  internal  coats  have  given  way,  and  the  sac 
is  composed  of  the  external  or  cellular  coat.  The  artery 
within  the  orbit  which  is  affected  by  aneurism  is  the  oph- 
thalmic, or  in  exceptional  cases  one  of  its  branches. 

Si/mpfoms  of  Aneurism  of  the  Ophthalmic  Artery. — 
Protrusion  of  the  eye,  but  if  the  vessel  has  not  burst,  the 
exophthalmos  is  not  extreme ;  pulsation  of  the  globe,  some- 
times visible,  but  nearlj^  always  to  be  felt  with  the  fingers 
on  the  eye ;  and,  lastly',  the  sense  of  pulsation  and  whir- 
ring noise  which  is  experienced  by  the  patient,  and  may 
be  generalljr  detected  by  the  medical  attendant  by  placing 
a  stethoscope  over  the  eye,  or  on  the  side  of  the  temple. 
There  is  often  an  absence  of  pain,  and  the  disease  may 
pass  for  a  long  time  unnoticed,  until  from  some  hidden 
or  accidental  causes  the  vessel  gives  way,  and  then  the 
suffering  becomes  extreme,  and  the  symptoms  exagger- 
ated. 

A  case  is  recorded  by  the  late  Mr.  Guthrie  of  aneurism 
of  the  ophthalmic  artery  of  both  sides.  The  disease  was 
diagnosed  during  life  and  verified  after  death,  when  "  an 
aneurism  of  the  ophthalmic  artery  was  discovered  on  each 
side,  of  about  the  size  of  a  large  nut."  .  .  .  .  "  The  dis- 


392  DISEASES    OF   THE    ORBIT. 

ease  existing  on  both  sides  prevented  nn  operation  on  the 
carotid  being  attempted,  to  -svliicli  indeed  the  patient 
wouki  not  have  submitted."* 

]Mr.  Nunneley  has  also  reported  the  post-mortem  exam- 
ination of  a  patient  whose  right  common  carotid  he  tied 
for  the  relief  of  orbital  aneurism.  The  operation  was  per- 
formed in  August,  1859,  and  the  woman  died  of  serous 
apoplexy  on  February  27,  1864.  "On  the  right  side  of 
the  sella  turcica  was  found  a  circumscribed  aneurism  of 
the  ophthalmic  artery,  just  at  its  origin,  as  large  as  a  hazel- 
nut, which  was  filled  witli  a  dense,  solid,  red  clot."f 

Cases  have  been  recorded  of  aneurism  of  the  central 
arter}'  of  the  retina.  In  a  patient  under  Dr.  G.  Sous,  of 
Bordeaux,  the  disease  Avas  diagnosed  during  life  b}'  the 
ophthalmoscope,  the  distended  vessel  appearing  as  an 
ovoid  tumor  on  the  left  optic  disc.| 

2.  The  Diffuse  or  Consecutive  Aneurism  is  when  an 
artery  has  been  ruptured  either  from  injur}-  or  disease, 
and  a  sac  has  been  formed  for  the  extravasated  blood  bj^ 
a  condensation  of  the  surrounding  tissues,  with  which 
sac  the  artery  communicates.  This  is  the  most  frequent 
form  of  orbital  aneurism.  It  may  arise  from  an  injur}', 
such  as  a  blow  on  the  side  of  the  head ;  or  it  may  come 
on  from  the  accidental  bursting  of  a  true  or  false  aneurism 
of  the  ophthalmic  arterj',  or  from  the  sudden  giving  way 
of  one  of  the  vessels  in  an  aneurism  by  anastomosis. 

The  symptoms  which  indicate  the  lesion  of  an  artery 
within  the  orbit  are  sudden  severe  pain,  followed  by  red- 
ness and  swelling  of  the  lids,  oedema  of  the  conjunctiva, 
and  protrusion  of  the  globe,  with  limitation  of  its  move- 
ments.    There  is  usualh",  in  addition,  noise  in  the  head, 

*  Lectures  on  the  Operative  Surgery  of  the  Eye,  p.  158. 
f  Medico-Chirurgical  Transactions,  vol.  xlviii,  18G5. 
J  Annales  d'Ociilistique,  1805. 


ANEURISM    OF    THE    OllCIT.  393 

compared  I\y  one  patient  to  the  whirring  sound  of  a 
steam-engine  or  threshing  machine,  and  by  another  to 
the  blowing  of  a  pair  of  bellows.  This  thrill  is  audible 
to  a  bystander  through  a  stethoscope  placed  over  the  eye 
or  on  the  side  of  the  temple.  A  slight  pressure  of  the 
fingers  on  the  eye  will  detect  pulsations  sjnchronous  with 
those  at  the  wrist.  In  some  cases  a  distinct  pulsating 
tmnor  may  be  felt  in  the  upper  region  of  the  orbit ;  but 
in  others  there  is  a  marked  absence  of  anything  like  a 
circumscribed  swelling.  Stooping  or  bending  the  head 
downwards  aggravates  all  the  symptoms.  Pressure  on 
the  common  carotid  at  once  arrests  pulsations  and  causes 
a  diminution  of  the  proptosis. 

The  suddenness  of  the  first  symptoms  is  well  illustrated 
in  the  following  extracts  from  three  of  the  reported  cases. 
Mr.  Travers,*  in  the  account  of  the  patient  whose  carotid 
he  tied  successfully,  says,  "  she  felt  a  sudden  snap  on  the 
left  side  of  her  forehead  which  was  attended  with  pain." 

Mr.  Dahymple  in  citing  the  history  of  the  case  in  which 
he  ligatured  the  carotid  for  aneurism  of  the  orbit,  uses  the 
patient's  own  words  :  "  The  attack  was  sudden — instan- 
taneous" .  .  .  .  "  hearing  a  noise  as  of  the  cracking  of  a 
whip,  and  feeling  at  the  same  moment  an  extraordinary 
kind  of  pain  in  the  globe  of  the  left  eye,  she  awoke  in 
great  alarm  and  leapt  out  of  bed. "f 

Lastly,  in  the  report  of  one  of  Mr.  Nunneley's  cases,  in 
w'hich  he  tied  the  carotid,  it  is  stated  that  "  as  she  stooped 
down  to  take  ofi"  her  shoe,  she  suddenly  felt  something 
give  wa}-  in  the  left  eye,  as  the  crack  of  a  gun."|  The 
poor  woman  died  on  the  sixteenth  day  after  the  operation, 
and  on  making  a  post-mortem  examination  there  was 
found  "  a  small  circumscribed  aneurism  of  the  carotid 

*  Medico-Cliirurgical  Trunsactioiis,  vol.  ii,  1811. 

t  Ibid.  vol.  vii,  1815.  J  Ibid.  vol.  xlii,  18G9. 


394  DISEASES    OF   THE    ORBIT. 

artery,  jnst  as  the  ophthalinie  Itranch  is  given  o(T,  -which 
at  its  origin  was  partly  surrounded  by  the  coaguliun  which 
had  escaped  from  tlie  vessel.  This  also  pressed  upon  the 
cavernous  sinus  ;  hence,  probabl}',  the  intense  congestion 
and  protrusion  of  all  the  structures  within  the  orbit."* 

In  each  of  these  three  cases,  a  series  of  distressing 
symptoms  followed  immediately  on  the  first  indication 
that  some  vessel  within  the  orbit  had  ruptured. 

T7'eatment  of  True^  Fahe,  and  Diffuse  Anetd'i^ms 
within  the  Orbit. — There  are  only  two  methods  of  dealing 
with  such  cases : 

(1.)  By  digital  compression  of  the  carotid  artery;  and 

(2.)  By  ligature  of  the  vessel. 

In  all  cases  where  it  is  practicable  digital  compression 
should  be  first  tried. 

In  July,  1856,  a  female  patient  with  aneurism  of  the 
ophthalmic  artery,  under  Professor  Gioppi,  of  Padua,  was 
successfully  treated  in  this  manner.  "  A  second  case,  in 
which  a  formidable  aneurism  of  the  ophthalmic  arteiy,  in 
a  patient  the  subject  of  aortic  and  cardiac  disease,  was 
cured  by  digital  compression,  was  published  in  1858  by 
Prs.  Yanzetti  and  Scaramuzza."f  It  is  not  necessary 
that  the  compression  should  be  continuous — it  may  be 
intermittent,  being  applied  only  five  or  ten  minutes  at  a 
time,  according  as  the  patient  can  bear  it.  If  this  treat- 
ment fails  to  effect  a  cure,  the  carotid  should  be  tied.  It 
is  an  oi)eration  which  has  been  frequently  performed  and 
with  good  success. 

3.  Aneurism  by  Anastomosis  is  usually  congenital,  al- 
though it  may  not  be  detected  until  by  its  increased 
growth  it  has  made  itself  manifest  by  extending  beyond 
the  orbit.     It  consists  of  a  morbidly  develo[)ed  network 

*  Tnmsactions  of  the  Putliological  Society,  vol.  xi,  p.  8. 
f  Holmes's  System  of  Surgery,  vol.  iii,.  pp.  423,  424. 


ANEURISM    OF    THE    ORBIT.  395 

of  capillaries  in  the  subcutaneous  cellular  tissue,  forming 
a  prominence  beneath  the  skin,  ^vhich  increases  in  size, 
and  is  rendered  turgid  bj'  laughing  or  crying.  To  the 
touch  it  has  a  tough  doughy  feeling,  quite  distinct  from 
fluctuation. 

Treatment. — When  the  vascular  gro^\th  is  of  limited 
extent,  and  is  only  a  short  distance  within  the  orbit,  it 
may  be  surrounded  subcutaneously  with  a  ligature  and 
tied.  The  same  proceeding  may  be  adopted  to  a  portion 
of  a  growth  of  a  larger  size  which  extends  beyond  the 
orbit.  There  are,  however,  cases  to  which  this  plan  of 
treatment  is  inapplicable,  as  when  the  growth  pulsates,  is 
of  great  dimensions,  bulges  the  eye,  and  is  rapidly  in- 
creasing. For  such  tumors  the  effect  of  temi)orary  pres- 
sure with  the  finger  on  the  carotid  should  be  tried,  and  if 
this  succeeds  in  arresting  the  pulsations  and  in  reducing 
the  fulness  of  the  growth,  the  artery  should  be  ligatured. 
Mr.  llaynes  Walton  succeeded  in  this  manner  in  curing 
a  large  aneurism  b}^  anastomosis  in  a  child  four  months 
and  three  weeks  old.  After  the  operation,  the  protrusion 
of  the  e^-eball  was  sensibly  diminished,  and  the  child  re- 
covered without  a  bad  symptom.* 

Dr.  Althaus  speaks  highly  of  the  success  he  has 
obtained  from  the  electrol3'tic  treatment  of  vascular 
growths. f  Although  4u  his  book  on  this  subject  he  has 
not  related  an}'  cases  of  large  aneurism  by  anastomosis 
in  which  he  has  used  electrol}- sis,  3'et  it  is  a  remedy  which 
fairly  commends  itself  for  trial  before  resorting  to  liga- 
ture of  the  carotid.  The  plan  of  injecting  the  tumor  with 
coagulating  fluids,  such  as  a  solution  of  tannin  or  of 
perchloride  of  iron,  is  fraught  with  danger,  and  should 
not  be  attempted. 

*  Haynes  Walton  on  the  Surgical  Diseases  of  the  Eye,  2d 
edition,  p  230. 

f  On  the  Electrolytic  Treatment  of  Tumors. 


396  DISEASES    OF   THE   ORBIT. 


EXOPHTHALMIC    GOITRE — GRAVES  S    DISEASE. 

The  three  sj'iiiptoms  which  characterize  this  extraorcli- 
nary  aftection  are :  exophthahnos  of  both  eyes,  enlarge- 
ment of  the  thyroid  gland,  and  palpitation  of  the  heart. 
To  these  niav  be  added  anaemia,  derangement  of  the  fnnc- 
tions  of  one  or  more  of  the  visceral  organs,  and  a  peculiar 
capriciousness  of  temper ;  bnt  these  signs  are  not  diag- 
nostic, as  the}'  are  common  to  other  diseases.  Exoph- 
thalmic goitre  is  more  frequent  amongst  women,  thus, 
''  of  fifty  cases  of  this  complaint  collected  by  Withuisen, 
only  eight  occurred  in  males."*  I  shall  first  briefly  de- 
scribe the  gronp  of  symptoms  which  mark  the  disease, 
and  then  refer  to  each  in  detail. 

Symjjfoms. — The  first  sj'mptom  is  usually  palpitation 
of  the  heart,  which  steadil}^  increases,  and  is  aggravated 
by  mental  emotion  or  exercise.  The  e^'es  seem  to  grow 
large,  and  the  friends  notice  that  they  begin  to  protrude, 
and  the  thj-roid  gland  expands.  The  patient  suffers  fi'om 
paroxysms  of  dyspnoea,  with  violent  palpitations,  and  a 
sense  of  fulness  of  the  ej'es  and  throbbing  of  the  carotids. 
Associated  with  these  s^Tuptoms  there  is  usually  anaemia, 
irregular  action  of  the  bowels,  an  uncertain  appetite,  and, 
if  the  patient  be  a  female,  amenorrhea.  Trousseau  lays 
emphasis  on  the  change  of  temper,  which,  from  being 
even,  becomes  capricious  and  irrital)le,  and  is  often  the 
first  indication  of  there  being  some  constitutional  malady. 

The  Exophthalmos^  or  protrusion  of  the  eyes,  is  the 
symi^tom  for  which  the  ophthalmic  surgeon  is  most  fre- 
quently consulted,  and  it  is  the  one  which  often  causes 
the  greatest  amount  of  anxiety  to  the  patient.  As  the 
disease  advances,  the  bulging  increases,  sometimes  to 
such  an  extent  as  to  prevent  the  lids  from  closing  over 

*  Trousseau's  Clinical  Medicine,  Syd.  Soc.  ed.,  vol.  i,  p.  0-32. 


EXOPHTHALMIC    GOITRE.  397 

the  globes.  When  this  happens,  the  eyes  suffer  from  ex- 
posure, and  become  liable  to  frequent  attacks  of  inflam- 
mation. In  a  poor  girl,  ait.  18,  who  was  under  my  care 
at  the  hospital,  the  eyes  continued  to  protrude  more  and 
more,  until  at  last,  having  lost  much  of  the  protection  of 
the  lids,  both  eyes  became  acutely  inflamed,  and  both 
corneae  suppurated.  I  frequently  see  this  patient,  and 
so  prominent  are  the  shrunken  globes,  that  although  both 
are  contracted  to  at  least  one-third  of  their  original  size, 
the  lids,  when  shut,  cannot  cover  them.  Notwithstand- 
ing the  prominence  of  the  ej^es,  the  sight  is  generall}'  but 
little  affected.  In  the  case  which  I  have  just  referred  to, 
the  girl  could  see  to  read  and  write  well  before  her  e^'cs 
became  inflamed. 

Hypei'trophy  of  the  Tliijroid. — The  whole  gland  is  usu- 
ally enlarged,  but,  according  to  Graves,  Stokes,  and 
Trousseau,  the  right  lobe  is  the  more  affected  of  the  two. 
In  three  out  of  the  four  cases  of  exophthalmic  goitre  re- 
lated by  Morell  Mackenzie,*  the  right  lobe  was  the  larger, 
and,  in  the  fourth,  both  lobes  were  equal.  The  increase 
in  the  size  of  the  thyroid  is  at  first  almost  imperceptible, 
but,  after  it  has  attained  certain  dimensions,  it  is  pro- 
ductive of  distressing  s^'mptoms  from  interfering  with 
respiration  when  the  patient  is  in  the  recumbent  position. 
With  the  h^^pertrophy  of  the  gland  tissue  there  is  dila- 
tation of  the  vessels  of  the  gland,  and  this  can  be  easily 
recognized  in  severe  cases,  by  placing  the  hand  over  the 
thyroid,  when  it  will  be  felt  to  expand  synchronously 
with  the  pulsations  of  the  carotids. 

Palpitation  of  the  Heart.  —  This  is  a  very  constant 
symptom,  and  usually  the  one  which  first  attracts  the 
patient's  attention.  Trousseau  saj's:  "The  valvular 
sounds  are  exaggerated,  and  are  generally'  accompanied 

*  Transactions  of  tlie  Clinical  Society,  vol.  i,  p.  9. 
.34 


398  DISEASES    OF    THE    0RI5IT. 

b}^  a  soft  systolic  Lellows-murnmr,  aiu]i])k'  in  the  lartie 
ai'teries  also.  The  carotids  pulsate  more  forcibly  than 
natural,  and  they,  as  well  as  the  jugular  veins,  have  a 
share  in  the  production  of  the  sounds  heard  over  the  en- 
larged thj-roid."*  The  palpitations  appear,  in  the  early 
stages  of  the  disease,  to  be  due  to  functional  derange- 
ment, but  in  the  latter  there  is  frequentl}-  dilatation  of 
the  cavities  of  the  heart. 

Derangement  of  the  Visceral  Organs. — The  appetite  is 
variable — at  one  time  good,  at  another  almost  wanting. 
The  bowels  are  irregular  in  their  action,  one  patient  suf- 
fering from  repeated  attacks  of  diaiTho?a,-»whilst  another 
is  troubled  with  flatus  and  constipation.  In  females  there 
is  very  frequently  amenorrhoea.  Trousseau  remarks:  "In 
the  beginning,  menstruation  is  only  disturbed,  but  it  is 
after  a  time  completely'  suppressed,  and  hopes  of  a  favor- 
able issue  are  not  to  be  entertained  until  this  function  is 
perfectly  re-established. "f 

Ansemia  generally  attends  this  disease,  but  it  is  by  no 
means  an  essential  condition,  as  exophthalmic  goitre  may 
exist  in  robust  and  florid-looking  patients. 

Treatment. — Dr.  Trousseau  says  :  "  I  can,  from  expe- 
rience recommend  j'ou  to  have  recourse,  in  this  singular 
afl'ection,  to  bleeding,  digitalis,  and  hydropathy."!  ^^^^ 
first  and  last  of  these  remedies  I  have  not  tried,  but  digi- 
talis I  have  frequently  ordered,  and  always  with  benefit. 
The  iodide  of  potassium  geuerall}'  fails  to  do  good  in 
these  cases;  it  depresses  too  much,  and  frequentl}'  in- 
duces iodism.  From  the  usualh'  anaemic  state  of  the 
patient,  iron  Avould  naturally  be  suggested,  but  with 
the  rapid  pulse  which  mostly  accompanies  this  disease, 
the  drug  is  badly  borne,  and  aggravates  the  s^'mptoms. 

*  Trousseau's  Clinicul  iNledicine,  Syd.  Soc  ed.,  vol.  i,  p.  54(). 
t  Ibid.,  p.  550.  X  Ibid.,  j).  588. 


TUMORS    OF    THE    ORBIT.  399 

During  the  paroxysms  of  dyspnoea,  ice  should  be  ap- 
plied over  the  thyroid  and  over  the  praecordial  region, 
in  an  india-rubber  ice-bag,  and  the  tincture  of  digitalis 
TT)j  10  to  "K  15  prescribed  every  two  or  three  hours,  keep- 
ing a  careful  watch  over  the  patient  during  its  adminis- 
tration. In  the  intervals  between  the  paroxysms,  small 
doses  of  the  tincture  of  digitalis,  combined  either  with 
the  mineral  acids  or  with  an  alkali,  according  to  the 
special  indications  of  the  case,  will  be  found  of  service. 
If  there  is  habitual  constipation,  the  bitter  waters  of 
PuUna,  Friedrichshall,  or  Kissingen,  may  be  also  pre- 
scribed. In  female  patients,  when  there  is  scanty  men- 
struation or  amenorrha^a,  means  should  be  taken  to  re- 
store the  uterine  functions.  In  cases  which  have  resisted 
medicinal  remedies,  I  would  certainly  try  a  course  of  hy- 
dropathy, witli  the  hope  that  by  acting  freely  on  the  skin 
the  patient  may  gain  that  relief  which  other  treatment 
had  failed  to  attbrd. 

TUMORS    or    THE    ORBIT. 

Tumors  of  the  Orbit  ma}'  be  divided  into  three 
classes : 

1.  Those  which  originate  within  the  orbit. 

2.  Those  which  commence  within  the  eye,  and  after- 
wards extend  to  the  orbit;  or  reappear  in  the  orbit  after 
the  eye  has  been  excised. 

3.  Those  which  have  their  origin  at  some  site  beyond 
the  eye  or  the  orbit,  but  have  extended  into  the  orbital 
cavity. 

It  would  be  out  of  place  to  discuss  in  this  manual  the 
nature  and  progress  of  all  the  varieties  of  tumors  which 
ma}'  affect  the  orbit,  as  nearly  every  form  of  tumor  which 
may  grow  elsewhere,  may  spring  u[)  also  in  this  localit3\ 
I  shall  therefore  allude  only  to  those  growths  which  have 


400  DISEASES    OF   THE    ORBIT. 

some  special  bearing  on  the  treatment  to  be  pursued  for 
their  removal. 

1.  Tumors  which  originate  within  the  orbit  soon 
manifest  their  presence  by  the  pressure  thej'  exert  on  the 
eye.  As  the  growth  advances,  the  globe  is  protruded  in 
one  or  other  direction,  according  to  the  position  the  tu- 
mor occupies  in  the  orbit.  All  sight  may  be  destroyed 
by  the  pressure  on  the  optic  nerve ;  or  by  the  stretching 
and  extension  of  the  nerve  from  the  protrusion  of  the 
eye ;  or,  if  the  exophthalmos  is  great,  the  lids  may  fail  to 
cover  the  globe,  and  the  cornea  may  ulcerate  and  slough 
from  exposure.  It  is,  however,  often  astonishing  to  what 
an  extent  the  eye  may  be  projected  and  the  optic  nerve 
consequently  stretched,  without  producing  any  great  im- 
pairment of  vision ;  and  also  how  the  lost  sight  will  be 
regained  after  the  eye  has  been  restored  to  its  proper 
position  within  the  orbit  by  the  removal  of  the  morbid 
growth.  The  tumors  which  originate  within  the  orbit 
may  be  benign,  recurrent,  or  cancerous ;  and  may  be  ex- 
tirpated with  more  favorable  prospects  of  success  than 
those  which  first  show  themselves  within  the  eye. 

Of  the  hcnign  growths  We  have  the  fibrous,  bonv,  and 
cartilaginous  tumors  and  cj^sts. 

Fibrous  tumors  usually  grow  from  the  periosteum  of 
the  orbit,  to  which  they  are  attached  bj-  either  a  broad  or 
a  pedunculated  base.  They  are  often  situated  near  the 
edge  of  the  orbit,  from  which,  with  care,  they  ma}^  be  re- 
moved without  injury  to  the  eye.  Tliese  tumors,  when 
carefully  dissected  out  with  the  portion  of  the  periosteum 
from  which  they  have  sprung,  do  not  reappear. 

Bony  and  Cartilaginous  Tumors. — The  exact  nature  of 
these  growths  can  only  be  ascertained  by  an  exploratory 
incision,  when,  if  they  are  attached  l»y  a  short  pedicle, 
they  ma}^  be  removed.    Occasionally,  however,  their  base 


TUMORS    OF    THE    ORBIT.  401 

is  SO  extensive,  and  their  structure  so  dense,  that  it  is  im- 
possible to  take  them  away.  For  the  excision  of  these 
tumors  the  operator  should  be  proA'ided  with  small  bone 
forceps,  a  gouge,  and  an  elevator,  as  even  when  the  pedi- 
cle is  small,  it  may  be  impossible  to  detach  it  without  the 
use  of  some  bone  instruments. 

Cysts  of  the  orbit  are  of  various  kinds.  The  most  fre- 
quent are  the  atheromatous  and  the  steatomatous,  but 
serous,  hydatid,  and  other  forms  of  cysts  are  also  met 
with  in  this  locality.  The  most  satisfactory  method  of 
dealing  with  cysts  is  to  dissect  them  out,  but  this  is 
often  extremely'  difficult,  and  occasionallj'  impracticable, 
without  sacrificing  the  e^'e.  The}'  sometimes  so  entwine 
themselves  amongst  the  orbital  muscles  that  it  is  hard  to 
follow  them  ;  and  their  Avails  are  frequently'  so  thin  that 
the3^  either  give  way  or  are  punctured  during  the  opera- 
tion, and  their  contents  having  escaped  it  becomes  almost 
impossible  to  identify  them  from  the  structures  in  which 
they  are  buried.  Unless  the  cyst  is  completely  excised, 
it  is  liable  to  grow  again.  If  the  cyst  is  large,  and  on 
making  an  exploratory  incision  into  it  its  contents  are 
found  to  be  fluid,  one  or  two  strips  of  lint  may  be  intro- 
duced into  its  cavit}',  after  it  has  emptied  itself,  with  the 
object  of  exciting  sufficient  inflammatory  action  to  cause 
obliteration  of  the  sac.  Occasionallj'  an  orbital  cyst  will 
be  found  to  contain  hydatids,  which  may  be  either  echi- 
nococci  or  cysticerci. 

Of  the  recurrent  grotrfhs^  the  most  frequent  is  the 
fijroid  recurrent  {the  spindle-celled  sarcoma).  This  tumor 
usually  grows  from  the  greater  part  of  the  periosteum 
lining  the  orbit,  and  can  onl}'  be  eradicated  b}'  completely 
extirpating  it,  and  then  destroying  the  whole  of  the  sur- 
face from  which  it  springs.  This  is  best  done  by  using 
the  chloride  of  zinc  after  the  tumor  has  been  excised  in 
the   manner  described   at   page    405,   in   the   section  on 

34* 


402  DISEASES    OF   THE    ORBIT. 

Treatment  of  Orbital  Tumors.  These  recurrent 
growths  differ  from  the  cancerous  tumors  in  that  thej'^  do 
not  invade  the  13'niphatics  or  affect  neighboring  organs. 

There  is  another  form  of  fibroid  tumor  which  is  recur- 
rent, but  in  a  different  sense  to  the  one  just  alluded  to. 
It  grows  from  onl}'  a  limited  area  of  the  lining  membrane 
of  the  orbit,  it  has  a  delicate  investing  capsule,  and  may 
be  pedunculated.  When  fairly  excised  with  the  portion 
of  the  periosteum  to  which  it  is  attached,  it  does  not  re- 
turn in  the  same  locality',  but  it  reappears  in  other  por- 
tions of  the  bod}',  generally'  selecting  for  itself  some 
fibrous  expansion  from  which  to  sprout.  I  have  had  one 
such  case  under  ni}^  care,  and  as  it  is  an  example  of  a 
rather  rare  form  of  disease,  I  will  brieflj^  quote  it.  In 
May,  1866,  I  removed  from  the  left  orbit  of  a  lady  a 
fibroid  tumor  of  six  3  ears'  growth.  It  was  pedunculated, 
inclosed  in  a  delicate  capsule,  and  attached  to  a  small 
portion  of  the  periosteum  of  the  outer  wall  of  the  orbit, 
which  I  also  excised  with  the  tumor.  From  this  opera- 
tion she  rapidly  recovered,  and  the  eye,  M'hich  had  been 
considerably  displaced  and  impaired  in  vision,  was  re- 
stored to  its  normal  position,  and  soon  regained  much  of 
its  lost  sight.  In  March,  1867,  the  patient  returned  to 
me  on  account  of  a  tumor  which  occupied  the  whole  of 
the  hard  and  a  portion  of  the  soft  palate  of  the  left  side. 
It  was  irregular  in  outline,  but  perfectly  smooth  and  very 
elastic.  It  was  first  noticed  about  four  or  five  months 
previously  as  a  small  swelling  in  the  upi)er  part  of  the 
left  hard  palate.  For  the  complete  removal  of  the  disease 
I  excised  the  whole  of  the  left  side  of  the  hard  palate,  and 
as  much  of  the  soft  palate  as  was  involved  in  the  disease. 
From  this  operation  also  the  patient  made  a  good  recovery. 
In  October  of  the  same  3'ear  she  again  came  to  me.  The 
disease  had  recurred  on  the  hard  jialate  of  the  right  side. 
There  was  also  a  fibroid  tumor  in  the  parotid  region  on 


TUMORS    OF    THE    ORBIT.  403 

the  same  side  of  the  face,  which  had  existed  some  years, 
and  had  now  begnn  to  increase  in  size.  I  accordingly 
removed  with  the  gouge  the  tumor  in  tlie  palate,  scoop- 
ing away  the  periosteum  and  the  corresponding  portion 
of  bone  to  which  the  growth  was  attached,  and  excised 
the  parotid  tumor.  From  this  operation  the  patient  soon 
recovered,  and  up  to  the  present  time,  June,  1869,  she 
has  continued  without  a  recurrence  of  the  disease. 

Of  the  cancerous  growths  which  may  originate  within 
the  orbit,  we  have  the  scirrhous,  medullary,  and  melanotic 
cancers.  The  two  last,  however,  more  frequently  first  ap- 
pear in  the  636,  and  afterwards  extend  to  the  orbit.  For 
the  treatment,  see  section  below. 

2,  The  Tumors  wniicn  first  commence  within  the 
Eye,  and  afterwards  extend  to  the  Orbit  ;  or  re- 
appear IN  THE  Orbit  after  the  Eye  has  been  ex- 
cised, are  the  medullar}^  and  melanotic  cancers,  and  the 
retinal  glioma.  See  articles  Medullary'  Cancer,  page 
230,  and  Glioma  of  the  Retina,  page  214.  Children 
are  more  liable  to  cancerous  affections  of  the  eye  and 
orbit  than  adults  ;  Leber*  has  found  that,  in  one-third  of 
the  cases  the  patients  were  under  ten  years  of  age.  For 
treatment,  see  section  below. 

3.  Tumors  which  have  their  origin  at  some  site 
beyond  the  Eye  or  the  Orbit,  but  have  extended 
into  the  Orbital  Cavity. — Such  growths  may  spring 
from  the  antrum,  the  frontal  sinuses,  the  lachrymal  ca- 
nals, or  from  some  of  the  bones  which  help  to  form  the 
base  of  the  skull,  as  the  pterygoid  processes,  or  the  body 
of  the  sphenoid.  In  all  cases  they  should,  if  practicable, 
be  removed,  and  at  as  early  a  period  as  possible.     Ex- 

*  Soelberg  Wells  on  the  Eye,  p.  648. 


-404  DISEASES    OF    THE    ORBIT. 

ami)les  of  remarkiible  displacement  of  the  e^-e  from  such 
growths  encroaching  on  the  orbit,  will  be  found  in  Heath's 
valuable  book  on  "Injuries  and  Diseases  of  the  Jaws," 
pages  238  and  247. 

TreatmeiU  of  Orbital  Tumor's. — In  all  cases  which  ad- 
mit of  a  reasonable  hope  of  success,  the  morbid  growth 
should  be  excised,  and  the  eye,  if  possible,  saved.  When 
the  tumor  is  cancerous  and  occupies  the  greater  part  of 
the  cavity  of  the  orbit,  the  eye  must  be  first  enucleated, 
even  though  it  still  retain  some  sight,  in  order  to  afford 
suflicient  space  for  the  complete  removal  of  the  growth. 
The  small  fibrous,  or  bony  and  cartilaginous  tumors,  or 
even  cysts,  ma}'  often  be  taken  from  the  orbit  without  in- 
jury to  the  eye.  The  morbid  growth  may  be  frequently 
removed  b}^  an  incision  through  the  conjunctiva,  and  es- 
pecially- if  the  globe  has  been  already  excised  ;  but,  when 
more  room  is  required,  the  external  cantlius  must  be 
freely  divided,  so  that  the  lids  may  be  turned  either  up- 
wards or  downwards,  and  thus  the  outer  boundary'  of  the 
orbit  be  completely  exposed.  Whenever  there  is  any 
doubt  as  to  the  nature  of  the  tumor,  the  surgeon  should 
make  an  incision  down  to  it,  but  be  prepared  to  act  at 
once  upon  the  information  which  he  thus  gains.  In  bony 
tumors  the  base  is  sometimes  found  to  be  so  large,  and 
the  structure  so  hard,  that  it  is  more  prudent  to  close  the 
wound  than  to  proceed  with  the  operation.  This  caution 
is  speciall}'  applicable  to  the  broad-based  ivor}^  exostoses 
Avhich  are  occasionally  met  with  in  the  orbit.  For  all 
the  malignant  and  recurrent  growths,  the  mere  excision 
of  the  disease  is  not  suflicient,  even  though  the  whole 
mass  be  apparently  taken  away,  as  some  germs  will  cer- 
tainly be  left,  which  will,  in  all  probability,  cause  the 
tumor  to  grow  again.  Having  excised  as  much  of  the 
tumor  as  can  witli  safety  be  removed  with  cutting  instru- 
ments, the   actual   cautery  should   be   freel}^  applied   to 


TUMOES    OF   THE    ORBIT.  405 

those  parts  of  it  which  still  remain,  and  to  all  the  bleed- 
ing points.  When  all  hemorrhage  has  been  arrested,  the 
chloride  of  zinc  i)aste  (F.  7)  spread  on  small  pieces  of 
lint,  shonld  be  laid  evenl}'^  over  the  whole  surface  from 
which  the  growth  has  sprung.  A  small  pledget  of  cot- 
ton-wool should  then  be  placed  in  the  orbit,  and  over  this 
a  fold  of  dried  lint,  which  is  to  be  held  in  situ  b}^  a  band- 
age tied  firndy  around  the  head.  Before  the  patient 
awakes  from  the  chloroform,  one-third  of  a  grain  of  the 
acetate  of  morphia  (F.  24),  should  be  injected  subcuta- 
neously  into  the  arm,  and  repeated  in  two  hours  if  the 
pain  be  severe.  The  pain,  a  er  this  operation,  is  usu- 
ally great,  but  it  is  much  lessened  if  the  strips  of  lint 
with  the  chloride  of  zinc  are  so  packed  in  the  orbit  that 
the  skin  of  the  lids  is  not  acted  upon  by  the  caustic  ;  but 
this,  in  many  cases,  is  quite  unavoidable,  as  the  tumor 
often  grows  from  the  periosteum  close  up  to  the  margin  of 
the  orbit,  and  some  of  the  chloride  of  zinc  is  then  almost 
certain  to  run  into  the  surrounding  tissues,  and  cause  a 
slough  of  a  portion  of  the  lids. 

On  the  day  following  the  operation,  the  bandage  may 
be  removed,  and,  if  there  is  much  tension  of  the  lids  from 
the  stuffing  within  the  orbit,  some  of  the  cotton-wool  may 
be  gently  drawn  out,  and  a  piece  of  clean  lint  being  laid 
over  the  parts,  another  bandage  should  be  lightly  applied. 
The  remainder  of  the  cotton-wool  shonld  be  taken  away 
on  the  second  day,  and  a  little  more  laid  loosely  within 
the  orbit  to  alisorb  the  discharge  as  soon  as  suppuration 
commences.  This  dressing  may  be  repeated  daily,  but 
the  pieces  of  lint  on  which  the  chloride  of  zinc  has  been 
applied  should  not  be  removed  until  suppuration  has  quite 
loosened  them  from  the  surface  against  which  they  were 
placed.  After  about  ten  or  twelve  days  the  sloughs  will 
separate  fr(  m  the  orbit,  and,  if  any  suspicious-looking 
granulations  spring  up,  they  should  be  touched  with  the 


406  DISEASES    OF   THE    ORBIT. 

solid  chloride  of  zinc,  or  with  the  potassa  cum  calce.  On 
three  occasions  I  have  seen  epileptic  convulsions  follow 
within  thirty-six  hours  after  the  operation,  but  they  have 
in  each  instance  ceased  shortly  after  the  removal  of  the 
cotton-wool  and  the  chloride  of  zinc  from  the  orbit.  The 
fits  did  not  recur,  and  the  patients  perfectly'  recovered. 

The  success  of  this  mode  of  treatment  has  been  well 
proved,  and  two  striking  instances  of  its  efficac}^  have 
been  recorded  in  the  "  Pathological  Transactions."  The 
first  was  in  a  patient  under  Mr.  De  Morgan,  who  removed 
a  large  encephaloid  tumor  from  the  orbit.  "It  projected 
nearly  four  inches  forward  from  the  cheek  on  the  outside, 
and  about  two  inches  and  three-quarters  from  the  nasal 
side."  *  The  man  died,  one  year  and  nine  months  after 
the  operation,  from  paraplegia,  but  there  was  no  return 
of  the  disease  in  the  orbit.  The  account  of  the  post- 
mortem examination  will  be  found  in  the  "Pathological 
Transactions,"  vol.  xviii,  page  220. 

The  second  case  was  a  patient  under  ra^'  care  in  the 
Middlesex  Hospital,  from  whom  I  i-emoved  a  scirrhous 
tumor  of  the  orbit.f  The  whole  of  the  bones  of  the  orbit 
wei-e  detached  in  one  piece,  and  are  to  be  seen  in  the 
museum  of  that  institution.  It  is  now  three  years  and 
five  months  since  the  operation,  and  the  patient  con- 
tinues quite  well,  and  free  from  an}"  recurrence  of  the 
disease. 

Acute  Inflammatory  Exudation  into  the  Orbit. — 
A  case  of  this  nature  was  under  the  joint  care  of  Dr. 
Goodfellow  and  myself  at  the  Middlesex  Hospital.  It 
presented  all  the  symptoms  of  a  rapidly  increasing  can- 
cerous tumor;  but  after  I  had  enucleated  the  e^'c,  and 

*  Pathological  Transactions,  vol.  xvii,  pp.  265-271. 
f  Ibid.,  vol.  xviii,  pp.  233-2o-j. 


INFLAMMATORY    EXUDATION.  407 

excised  the  solid  growth  Avhith  filled  the  orbit,  it  proved 
on  a  microscopical  examination  to  be  perfectly  structnre- 
less,  and  was  probabl}'  the  product  of  acute  inflammation, 
most  likel}^  specific.  The  man  continued  in  the  hospital 
until  his  death,  five  months  afterwards,  when  a  post- 
mortem examination  explained  most  of  the  symptoms 
observed  during  life.  A  short  account  of  the  case  was 
given  in  the  "Lancet,"*  from  which  I  have  abstracted 
the  following  notes : 

The  patient  was  under  the  care  of  Dr.  Goodfellow  in 
one  of  the  medical  wards;  after  suffering  much  pain,  the 
e^'e  within  twent3-four  hours  was  found  to  bulge  consid- 
erably. There  was  paralysis  of  all  the  ocular  muscles, 
great  impairment  of  sight,  and  Q?dema  of  the  lids,  with 
slight  chemosis  of  the  conjunctiva.  I  was  asked  to  see 
the  man,  and  believing  from  the  rapidity  of  the  symptoms, 
that  they  were  due  to  some  kind  of  inflammatory  exuda- 
tion, I  thrust  a  bistoury  into  the  orbit  through  the  upper 
lid.  Onlj'^  a  little  serum  escaped.  The  bulging  of  the  eye 
steadily  increased,  and  with  it  the  swelling  of  the  lids 
and  chemosis  of  the  conjunctiva.  The  pain  in  the  head 
and  orbit  at  times  was  very  considerable,  and  twice  it 
was  relieved  b}'  some  leeches  to  the  temple.  Iodide  of 
potassium  was  administered  in  large  doses,  but  without 
affording  any  relief.  The  urgent  symptoms  continued, 
the  eye  became  quite  blind  and  immovable,  and  began 
to  suppurate.  As  the  eye  was  now  lost,  and  the  man's 
sutferings  were  extreme,  I  excised  the  globe,  and  then 
came  down  upon  a  hard  conical-shaped  mass,  which  ex- 
actly filled  the  whole  of  the  orbit.  The  periorbital  mem- 
l)rane  was  in  situ  with  the  bone,  and  the  tumor  corre- 
sponded with  the  cone  which  is  formed  l\y  the  muscles 
and  vessels  as  they  pass  from  the  apex  of  the  orbit  to  the 

*  See  Lancet,  April  18,  18G8. 


408  DISEASES    OF    THE   ORBIT. 

e3'e.  I  removed  as  mneh  of  this  solid  material  as  I  was 
able,  leaving-  onl}"  a  small  portion  at  the  veiy  apex  of  the 
orbit,  which  I  felt  it  would  be  unsafe  to  meddle  with. 
Examined  with  the  microscope  b}'  Messrs.  De  Morgan, 
Hulke,  and  Ca3'ley,  the  conclusion  was,  that  this  solid 
mass  was  only  inflammatory  exudation  ;  it  was  perfectly 
structureless.  The  following  day  the  man  had  three  epi- 
lejjtic  fits,  but  from  these  he  recovered,  and,  so  far  as  the 
orbit  was  concerned,  he  afterwards  did  perfectl}^  well. 
There  was  very  free  suppuration,  which  was  followed  by 
complete  cicatrization. 

For  the  first  fortnight  after  the  operation,  the  man 
seemed  decidedly  relieved,  but  the  pain  in  the  head  then 
returned ;  and  on  awaking  one  morning  he  found  the  left 
half  of  his  face  paralyzed.  He  was  then  transferred  to  the 
physicians'  wards,  where  he  graduall}'  became  hemiplegic, 
in  which  condition  he  remained  until  he  died. 

Post-mortem  examination  ten  hours  after  death.  Rigor 
mortis  strongly  marked.  Body  much  wasted ;  nodes  on 
the  right  tibia.  On  removing  the  scalp,  the  outer  table 
of  the  skull  presented  a  curious  worm-eaten  appearance, 
and  the  bone  was  adherent  at  points  to  an  irregularly 
thickened  dura  mater.  In  the  substance  of  the  left  cere- 
bral hemisphere,  near  the  front  of  the  upper  surface,  was 
a  nodule  of  firm  gra^'ish  syphilitic  deposit,  the  size  of  a 
filbert.  At  the  surface  of  the  corresponding  part  on  the 
right  side,  where  the  pia  mater  adhered  to  the  brain, 
there  was  a  circumscribed  abscess.  There  was  also  an- 
other abscess,  of  the  size  of  a  hazel-nut,  in  the  substance 
of  the  left  cerebellar  hemisphere.  There  was  necrosis  of 
the  petrous  portion  of  the  left  temporal  bone,  with  an 
abscess  above  it  leading  into  the  left  inferior  petrosal  and 
left  lateral  sinuses,  both  of  which  were  filled  with  pus. 

Cases  of  acute  inflammatory  exudation  into  the  orbit 
are  no  doubt  rare,  but  1  suspect  that  they  are  more  fre- 


DISTENSION    OF    THE    FRONTAL    SINUS.  409 

quent  than  the  hospital  records  would  lead  us  to  antici- 
pate. It  is  onl}'  on  this  supposition  that  I  can  account 
for  the  occasional  instances  which  one  meets  with  in 
practice  of  the  gradual  subsidence,  without  operative 
treatment,  of  firm  orbital  tumors,  which  had  considerably 
displaced  the  eye,  and  had  been  readily  felt  with  the 
finger  in  the  orbit.  In  October,  18GG,  I  saw  in  consul- 
tation with  Dr.  Stallard  a  patient,  vet.  20,  whose  right 
eye  was  protruded  rather  more  than  half  an  inch  from 
the  orbit  by  a  firm  growth,  the  margin  of  which  could 
be  distinctly  felt  with  the  tip  of  the  finger  pressed  within 
the  orbit.  The  eye  began  to  bulge  suddenly  in  the  pre- 
vious May,  after  a  considerable  swelling  of  the  face,  for 
which  he  had  a  tooth  removed ;  and  from  that  date  up  to 
the  time  I  saw  him,  the  proptosis  had  continued  to  in- 
crease. Thinking,  from  the  history  of  the  case,  that  the 
symptoms  might  be  due  to  some  inflammatory  exuda- 
tion, I  thrust  a  bistoury  through  the  upper  lid  in  two 
places  into  the  orbit,  but  only  a  little  blood  escaped.  He 
was  then  ordered  a  mixture  with  iodide  of  potassium,  and 
since  then  he  has  steadily  improved.  The  tumor  within 
the  orbit  has  so  far  subsided,  and  the  e3'e  has  resumed 
so  nearly  its  normal  position,  that  an  ordinary  observer 
would  fail  to  notice  any  dift'erence  in  the  prominence  of 
the  two  eyes. 

DISTENSION    or    THE    FRONTAL    SINUS. 

The  frontal  sinus  may  be  distended  with  pent-up  secre- 
tion, or  pus,  and  the  tumor  thus  formed  may  so  closely 
resemble  a  growth  from  within  the  orbit,  as  to  render  it 
difficult  to  arrive  at  a  correct  diagnosis  without  making 
an  exploratory  incision.  In  order  to  rightly  estimate  the 
displacement  of  the  globe  which  an  expanded  frontal 
sinus  may  produce,  it  will  be  necessary  to  refer  briefly 
to  the  anatomy  of  the  dry  skull. 

35 


410  DISEASES    OF   THE    ORBIT. 

The  frontal  sinuses  are  two  bony  cavities  placed  between 
the  inner  and  outer  tables  of  the  vertical  portion  of  the 
frontal  bone,  conipletel}'  separated  from  each  other  by  a 
bon}'  septum.  Each  of  these  spaces  is  subdivided  into 
cells  b}'  delicate  lamellte  of  bone.  These  cells  extend  up- 
wards about  one  inch,  gradually  becoming  narrower  as 
they  ascend,  until  the  opposed  plates  of  the  frontal  bone 
come  almost  into  contact,  a  thin  layer  of  diplo'e  only  in- 
tervening. Forwards  and  outwards  the  frontal  cells  are 
prolonged  between  the  layers  of  bone  which  form  the  roof 
of  the  orbit  as  far  as  the  mesial  line  of  that  cavity,  at 
which  part  they  cease,  from  the  opposed  laminae  of  bone 
falling  together.  The  half-cells  which  are  seen  in  the  dry 
frontal  bone  at  the  nasal  notch,  are  completed  b}'  corre- 
sponding half  cells  on  each  side  of  the  cribriform  plate  of 
the  ethmoid  bone.  The  frontal  cells  communicate  with 
the  middle  meatus  of  the  nose  by  means  of  the  infundi- 
bulum,  which  is  a  long  and  tortuous  bony  canal,  connect- 
ing the  anterior  ethmoidal  cells  with  the  frontal  sinus 
above,  and  with  the  meatus  of  the  nose  below. 

The  situation  of  the  frontal  sinuses  is  indicated  on  the 
exterior  of  the  frontal  bone  b}'  two  prominences  over  the 
root  of  the  nose,  more  or  less  strongl}'  marked  in  all 
people,  and  called  the  nasal  eminences. 

Such  being  the  disposition  of  the  frontal  cells,  it  is  eas}' 
to  conceive  in  what  direction  a  new  growth,  or  an  accu- 
mulation of  fluid,  would  cause  them  to  distend.  Of  their 
boundar}'  walls  the  weakest  is  that  towards  the  orbit, 
where  the  bony  plate  which  separates  that  cavity  from 
the  frontal  sinus  is  exceedingly  thin,  and  often  in  the  dry 
skull  semi-transparent;  so  delicate  indeed  in  structure  is 
the  iipper  and  inner  part  of  the  orbit,  that  the  linger, 
in  many  of  the  drj-  preparations,  may  be  easily  pushetl 
through  it. 

Causes. — In  most  cases,  distension  of  the  frontal  sinus 


DISTENSION    OF   THE    FRONTAL   SINUS.  411 

is  due  to  iiii  iiymy  at  some  remote  period,  frequently  at 
a  date  so  far  from  the  s^'iiiptoms  which  first  attracted  the 
patient's  notice,  tliat  it  seems  at  first  diflicult  to  fairly 
attribute  the  disease  as  the  result  of  an  accident.  The 
extent,  however,  to  which  the  sinus  is  often  found  dilated, 
and  the  time  which  must  necessarily  be  consumed  to  effect 
this  distension  of  a  bon}^  cavity,  together  with  the  oft-told 
tale  of  a  blow  or  a  fall  years  ago,  can  only  lead  to  the  con- 
clusion that  an  injury  is  the  most  frequent  exciting  cause 
of  these  accumulations.  The  explanation  is  probably  to 
be  found  in  the  supposition,  that  at  the  time  of  the  acci- 
dent a  fracture  of  some  of  the  anterior  ethmoidal  or 
frontal  cells  produced  a  closure  of  the  infundibulum,  the 
canal  by  which  the  mucus  from  the  frontal  sinus  escapes 
into  the  nose.  This  channel  being  closed,  there  was  at 
once  a  retention  of  all  mucous  secretion,  wdiich  from  that 
time  began  to  slowly  accumulate  and  gradually  expand 
the  sinus.  In  a  patient,  set.  58,  under  my  care,  with  an 
enormous  distension  of  the  left  frontal  sinus,  the  disease 
was  clearly  traceable  to  a  kick  he  received  on  the  left  eye- 
brow from  a  horse  fifty-four  years  previously,  when  four 
3'ears  of  age.  There  was  a  depression  of  the  bone  over 
the  left  eyebrow,  and  a  scar  at  the  side  of  the  nose. 

A  case  also  is  recorded  by  Mr.  Hulke,  of  a  girl,  set.  lY, 
with  great  expansion  of  the  right  frontal  sinus,  which  was 
evidently  caused  by  an  accident  when  she  was  five  years 
of  age.  "  She  fell  from  a  window  and  received  a  cut  over 
the  right  eyebrow^  Her  forehead  was  much  bruised  and 
swollen,  and  she  had  concussion  of  the  brain."* 

There  are,  however,  cases  of  distended  frontal  sinus,  in 
which  no  history  of  an  injury  can  be  traced.  The  only 
conclusion  which  can  then  be  drawn  is,  that  from  some  ac- 
cidental cause  which  we  cannot  detect,  the  communica- 

*  Koyal  London  Ophthuhiiic  Hospital  Eeports,  vol.  iii,  p.  153. 


412  DISEASES    OF   THE    ORBIT. 

tion  between  the  frontal  cells  and  the  nose  throngh  the  in- 
fundibulum  has  been  closed,  possibh'  from  some  inflam- 
mation of  the  lining  mucons  membrane.  This  hypothesis 
seems  probable,  as  in  the  case  of  a  yonng  girl,  a?t.  21, 
who  was  under  my  care,  the  disease  Avas  dated  from  an 
attack  of  erysipelas  of  the  head  and  face  when  she  was  six 
years  old,  dnring  which  there  was  a  thick  discharge  from 
the  nares. 

Si/mjjtoms — Distension  of  the  frontal  sinns  ma}'  be 
acute  or  chronic. 

When  the  distension  is  acitfe  it  is  dne  to  inflammation 
of  the  mucons  membrane  of  the  sinus,  which  leads  to  the 
formation  of  pus.  There  is  generally  a  dull  aching  pain 
over  the  brow  and  root  of  the  nose,  accompanied  by  con- 
siderable constitutional  disturbance.  The  pus  gradually 
accumulates  in  the  frontal  sinus,  and  ultimately  dis- 
charges itself  either  by  bursting  into  the  nose,  or  by 
making  an  exit  for  itself  through  the  upper  and  inner 
part  of  the  orbit.  When  the  latter  site  is  selected  there 
is  usually  some  bulging  of  the  distended  sinus  into  the 
orbit,  and  a  slight  displacement  of  the  eye  downwards  and 
outwards.  The  upper  lid  becomes  red  and  swollen,  and 
the  tumor  examined  with  the  finger  is  tender,  and  will,  if 
sufficient  thinning  of  the  bone  has  taken  place,  impart  a 
sense  of  fluctuation. 

In  most  cases  the  distension  of  the  frontal  sinus  is 
chro7iic,  and  the  collection  of  fluid  within  its  walls  is  the 
pent-up  secretion  of  many  j^ears.  Sealed  within  a  bou}^ 
cavit}',  no  decomposition  ensues,  and  increasing  year  b}' 
3'ear  in  quantity  it  distends  the  sinus  and  displaces  the 
eye.  There  is  frequently  no  pain,  not  even  a  sense  of 
weight  over  the  brow.  The  only  symptoms  which  are 
manifest  to  the  patient  are,  the  gradual  formation  of  a 
tumor  at  the  upper  and  inner  portion  of  the  orbit,  and  a 
slow  but  steadily  increasing  protrusion  of  the  eye  down- 


DISTENSION    OF    THE    niONTAr^    SINUS.  413 

Avaids,  outwards,  and  forwards.  In  one  patient  under  m}^ 
care  the  displacement  was  so  extreme  that  the  upper  mar- 
gin of  the  cornea  of  the  left  Qye,  was  below  the  level  of  the 
right  lower  lid.  Occasionally  the  early  symptoms  are 
chronic,  whilst  the  later  ones  are  subacute,  and  produc- 
tive of  a  feeling  of  constant  heaviness  and  aching  across 
the  forehead.  The  disease  is  usually  confined  to  the 
frontal  sinus  of  one  side,  but  a  case  occurred  under  Mr. 
llulke  of  a  man  in  whom  both  frontal  sinuses  were  af- 
fected. 

Treatment  of  Distension  of  the  Fi-ontal  Sinus — The 
objects  to  be  attained  are,  first,  to  evacuate  the  pent-up 
fluid,  and  then  to  establish  a  free  communication  between 
the  frontal  sinus  and  the  nose,  through  which  the  secre- 
tion may  continue  to  drain  as  fast  as  it  is  secreted.  By 
these  means  the  cavit}^  of  the  sinus  will  gradually  collapse, 
and  the  eye  will  be  restored  in  a  great  measure  to  its  nor- 
mal position.  The  ends  to  be  desired  will  be  accomplished 
by  the  following  operation  : 

A  single  curved  incision  parallel  with  the  fold  above 
the  lid  is  to  be  made  over  the  most  prominent  part  of  the 
tumor,  and  having  by  a  little  dissection  exposed  Its  sur- 
face, the  scalpel  should  be  plunged  into  it,  and  an  opening 
made  to  the  extent  of  the  incision.  The  index  finger  of 
the  right  hand  is  now  to  be  pushed  into  the  sinus  through 
the  wound  to  ascertain  the  size  of  the  cavity  and  if  there 
is  any  necrosed  or  carious  bone.  Whilst  thus  exploring 
the  sinus,  the  little  finger  of  the  left  hand  should  be  passed 
up  the  corresponding  nostril  and  an  endeavor  made  to  find 
out  the  spot  at  which  the  tip  of  the  finger  in  the  sinus  will 
approximate  most  closely  the  end  of  the  one  in  the  nose. 
After  a  little  search  it  will  be  found  that  at  one  part  the 
fingers  will  almost  meet,  there  being  only  a  thin  plate  of 
bone  between  them.  Having  gained  this  information,  the 
finger  in  the  frontal  sinus  is  to  be  withdrawn,  but  that  in 

35* 


414  DISEASES    OF   THE    ORBIT. 

the  nostril  is  to  be  retained  in  situ  to  act  as  a  gnide  to 
the  gonge  or  elevator,  which  is  to  be  passed  into  the  sinus 
and  made  to  force  a  passage  into  the  nose  through  the 
lamina  of  bone  on  which  the  tijD  of  the  little  finger  is  rest- 
ing. A  communication  between  the  frontal  sinus  and  the 
nose  having  been  thus  established,  an  india-rubber  drain- 
age tube  with  holes  cut  at  short  distances  is  to  be  intro- 
duced, one  extremit}^  of  Avhich  is  to  be  afterwards  fastened 
on  the  forehead,  whilst  the  other  end  protrudes  slightly 
from  the  nostril. 

The  easiest  wa^y  of  introducing  the  drainage  tube  is  to 
pass  a  probe  with  an  eye  up  the  nostril  and  out  of  the 
wound,  and  having  fastened  the  tube  to  it  by  means  of  a 
piece  of  string,  to  draw  it  back  again  through  the  nose. 

The  object  of  the  drainage  tube  is  to  keep  the  channel 
between  the  two  cavities  from  closing,  and  to  enable  the 
attendant  to  wash  out  the  frontal  sinus  at  least  twice  a 
da}'  with  some  astringent  and  disinfectant  solution.  For 
the  latter  purpose  the  lotio  alum,  cum  zinc,  sulph.,  or  the 
lotio  acid,  carbolic.  (F.  40,  45),  may  be  injected  wdth  a 
glass  S3'ringe  through  one  of  the  openings  at  the  upper 
extremit}'  of  the  tube.  The  drainage  tube  should  be  worn 
for  five  or  six  months,  or  until  all  discharge  from  the  nose 
has  ceased.  The  results  of  these  cases  when  thus  treated 
are  usuall}'  most  satisfactory. 


FORMULARY. 


1.  Liebreich's  Eye  Bandage. 


Tlie  bandage  consists  of  a  linen 
or  a  knitted  cotton  band,  ^,from 
10  to  10^  inches  in  length,  and 
2^  inches  in  width;  at  either  end 
of  which  are  attached  tapes  to 
keep  it  in  position  on  the  head. 
Tlie  tapes  should  be  one  ingh  in 
width.  One  tape,  B,  \\^  to  12 
inches  in  lengtli,  extends  across 
the  top  of  the  head  from  ear  to 
ear  and  terminates  in  a  loop, 
through  which  the  second  tape, 
CD,  passes,  as  in  the  wood-cut. 
To  apjjly  the  bandage  : 
The  patient  having  been  told 
to  gently  close  the  lids  of  both 
eyes,  a  small  square  of  linen  is 
laid  over  each,  upon  which  are 
placed  small  pads  of  eotton-wool 
or  charpie.  The  bandage,  which 
had  been  previously  fitted  to  the 
head,  is  now  drawn   acros.s  the 


eyes  and  fastened  on  the  temple, 
opposite  to  the  eye  which  has 
undergone  the  operation. 

2.  The  Compress  Bandage. 

"This  bandage  should  be  about 
If  yards  in  length, and  1^  inches 
in  width;  the  outer  two-thirds 
should  consist  of  tine  and  very 
elastic  flannel,  the  central  third 
of  knitted  cotton.  The  eye  hav- 
ing been  padded,  the  bandage  is 
to  be  adjusted  in  the  following 
manner  : — One  end  is  to  be  ap- 
plied to  the  forehead  just  above 
the  affected  eye,  and  is  then  to 
be  passed  to  the  opposite  side  of 
the  forehead,  above  the  ear,  to 
the  back  of  the  head  :  the  knitted 
portion  is  then  to  be  carried  on 
below  the  ear,  and  brouglit  up- 


416 


FORMULARY. 


wards  over  the  compress,  the 
bandage  being  passed  across  the 
forehead,  and  ils  end  liinily 
pinned.  The  opposite  eye  ma\' 
be  closed  with  sticking  piiister, 
or  if  it  also  requires  a  compress, 
a  separate  bandage  is  to  be  ap- 
plied to  it  "* 

In  the  place  of  the  flannel  and 
knitted  cotton  bandage  iibove 
described,  a  fine  linen  one  will 
answer  equally  well. 

3.  Mercurial  Vapor  Bath. 

The  following  is  Mr.  Henry 
Lee's  description  of  his  mercu- 
rial vapor  bath.  "  It  consists  of 
a  kind  of  tin  case,  containing  a 
spirit  lamp.  In  the  centre,  im- 
mediately over  the  wick  of  the 


lamp,  is  a  small  circular  tin  plate, 
upon  which  the  mercurial  pow- 
der is  placed.  Around  this  is  a 
circular  depression,  which  is  half 
filled  with  boiling  water.  The 
patient  places  this  on  theground, 
and  sits  over  it,  or  near  it,  on  a 
small  cane  stool.  He  is  then  en- 
veloped, lamp  and  all,  in  a  cir- 
cular cloak,  made  expressly-  for 
this  purpose  by  Messrs.  Savigny. 
"When  a  cloak  cannot  be  pro- 
cured, a  double  blanket  answers 
the  purpose  very  well.  At  the 
expiration  of  a  quarter  of  an 
hour    or    twenty    minutes,    the 

*  "  Observations  on  Compressive  Band- 
ages," by    Prof.  Von   Graefe,    abridgei)  | 
and  translated  by  Soel berg  Wells, /f.  Z<. 
O.  U.  Rip.,  vol.  iv,  p.  206.  I 


calomel  which  is  placed  upon 
the  lamp,  the  water,  and  the 
spirit  will  have  disappeared,  and 
the  patient  may  then  get  into 
bed.  During  the  time  the  pa- 
tient is  taking  the  bath,  he  may 
inhale  the  vapor  for  half  a  min- 
ute or  a  minute,  on  two  or  three 
ditt'erent  occasions,  with  advan- 
tage; and  after  the  bath  is  over 
he  must  contrive  not  to  wipe 
otf  the  calomel  deposited  on  his 
skin.  Patients  are  generally  n-- 
commended  to  sit  over  the  bath 
for  two  or  three  minutes  after 
the  lamp  has  gone  out."* 

The  lamp  maj'  be  obtained  of 
Messrs.  Weiss,  Savigny,  Mat- 
thews, or  any  of  the  London 
surgical  instrument  makers. 


4.  Lapis  Divinus. 

Sulphate  of  Copper,  iS'itrate 
of  Potash,  and  Alum,  of  each 
equal  parts,  in  powder,  fused  in 
a  glazed  earthen  crucible,  pow- 
dered Camphor,  to  the  extent  of 
Jq  part  of  the  whole,  being  added 
near  the  end  of  the  process. 
When  cold,  break  in  pieces  and 
keep  in  a  closelj'-stoppered  bot- 
tle.f 

5.  Diluted  Nitrate  of  Silver 
Points. 

These  are  made  by  fusing  Ni- 
trate of  Potash  in  various  pro- 
portions with  Nitrate  of  Silvi^r; 
thus:| 

No.  1  consists  of  1  Nitrate  of 
Silver  and  2  of  Nitrate  of 
Potash. 


*  Article  "Syphilis,"  Holmes's  Sys- 
tem of  Surgery,  by  Henry  Lee,  vol.  i.  p. 
i-21. 

t  Squire's  Comp.  to  Brit.  Pharmacnp., 
5th  edit.,  p.  96. 

X  Ibid.,  p.  40. 


FORMULAEY. 


417 


No.  2  consists  of  1  Nitrate  of 

Silver    and    8    of  Nitrate  of 

Potash. 

No.  3  consists  of  1  Nitrate  of 

Silver  and   3|    of  Nitrate  of 

Potash. 

No.  4  consists  of   1  Nitrate  of 


Silver    and 
Potash. 


4    of   Nitrate  of 


6.  Pulvis  Caustica. 

R.  Zinci  Chloridi    )      Partes 
Zinei  Oxydi,        j     aHiiiales. 
Jlix  them  intimately  with  pes- 
tle and  mortar.     Preserve  in  a 
well-stoppered  bottle. 

7.  Pasta  Caustica. 

R.  Zinei  Chloridi,  .  .  gr.  480 
Farinaj,  .  gr.  120,  vel  q.  s. 
Liquoris  Opii  Sedativi 

vel  Aquie, .     .     .     11.  oz    1 
Misce. 

8.  Fotus  Belladonnse. 

Extract.  BeUadonnie,  .        gr.  60 
To  be  dissolved  in  one  pint  of 
boiling  water,  and  used  as  a  fo- 
mentation. 

9.  Fotus  Papaveris. 

R.  Capsiil.  Papav.  contus.,  oz.  1 

Aquse  destillat.,      .  fl    oz.  20 

Mix,   and   boil   for  a  quarter 

of  an  hour;  then  strain  through 

muslin. 

10.  Gargarisma   Acidi  Hy- 
drochlorici. 

R.  Acid.  Hydrochlorici, 

diluti.,  .     .     .     .     fl.  dr.  2 
Decoct.  Querciis,    .  fl.  oz.  20 
JVlisce. 

11.  Gargarisma  Aluminis. 

R.  Aluminis,      .     .  .      gr.  120 

Tinct.  Myrrhaj,  .     fl.  dr.  4 

Aqu;e  destillat.,  ad  fl.  oz.  20 
Misce. 


12.  Gargarisma  Sodse  Chlo- 

ratae. 

R.  Liq.  Soda?  Chlorata\  fl.  dr.  4 
Aquie  destillat.,     ad  fl.  oz.  8 
Misce. 

13.  Guttse  Atropiae  Sulpha- 

tis. 

R.  Atropiie  Sulphatis,   gr.  1  ad 
gr.  2 
Aqufe  destillat.,      .     fl.  oz.  1 
Misce. 

14.  Guttae  Atropiae  Sulphatis 

Fortiores. 

R.  Atropi;p  Sulphatis,     .     gr.  4 
Aqua)  destillat.,      .     fl.  oz.  1 
Misce. 

15.  Guttae  Physostigmatis 
Fabae  (Calabar  Bean). 

Extracti  Physostigmatis 

Fa  has,  .     .     .     gr.  1  ad  gr.  4 

Aquie  destillat.,       .     .     fl.  dr.  1 
Misce. 

16.  Guttae  Argenti  Nitratis. 

R.  Argenti  Nitratis,   .     .    gr.  1 
Aquie  destillat.,      .     fl.  oz.  1 
Misce. 

17.  Guttae  Argenti  Nitratis 

Fortiores. 

R.  Argenti  Nitratis,  .     .    gr.  2 
Aquiv  destillat.,      .     fl.  oz.  1 
Misce. 

18.  Guttae  Potassii  lodidi. 

R.  Potassi  lodidi,  .     .     .     gr.  3 
Aquffi  destillat.,      .     fl.  oz.  1 
Misce. 

19.  Guttae  Zinci  Chloridi. 

R.  Zinci  Chloridi,  gr.  1  ad  gr.  2 
Aqua' destillat.,      .     fl.  oz.  1 
Misce. 


418 


FORMULARY, 


20.  GuttsB  Zinci  Sulphatis. 

U-  Zinci  Sulphiitis,  gr.  1  nd  gr.  2 
Aqiiie  destillut.,       .      fl.  oz.  1 
Misce. 

21.  Guttse  Cupri  Sulphatis. 

R.  Cn]iri  Siilpliatis,     .     .    gr.  2 
Aqiiie  destillat.,      .     fl.  oz.  1 
Misce. 

22.  Guttse  Opii. 

R.  Vini  Opii,     .     .     .     fl.  dr.  2 
Aqune  destilhit.,      .     fl.  dr.  6 
Misce. 

23.  Guttae  Terebinthinae. 

R.  01.  Tercbinthiiue,  .     fl.  dr.  1 
01.  Olivje,      .     .     .     fl.  dr.  7 
Misce. 

24.  Injectio  Morphiae. 

R.  Morphiae  Acetjitis,  .  gr.  80 
Aquse  destillat.,      .     fl.  oz.  1 

Eub  the  Morphia  gradually 
with  the  water,  and  add  a  few 
drops  of  dilute  Acetic  Acid,  if 
necessary  for  perfect  solution. 

Min.  6  contain  gr.  1  of  Acetate 
of  Morjihia. 

25.  Liniment.  Aconiti. 

R.  Linimenti  Aconiti,     fl.  dr.  4 
Linimenti  Saponis,     fl.  dr.  6 
Misce. 

26.  Liniment.  Ammoniae. 

R.  Liq.  Ammonite,     .     fl.  dr.  4 
Ol.   OlivEe,     .     .     .     fl.  dr.  4 
Misce. 

27.  Linimentum  Belladonnse 
cum  Glycerino. 

R.  Extracti  Belladonnfe, 

Glycerini,    .     .     fia  fl.  oz.  1 

Misce. 


28. 


Linimentum  Chloro- 
formi. 


R.  Chloroform!, 
Ol.  Olivse,      . 
Misce. 


fl.  dr.  4 
fl.  dr.  4 


29.  Linimentum  Calcis  cum 
Creta. 

R.  Olei  Lini, 

Liquoris  Calcis,      afi  fl.  oz.  4 
Cretse  preparataj,    .     .     uz.  2 
Misce. 


.  oz.  1 
.  gr.  25 
fl.-dr.  6 
fl.  dr.  2 
min.  30 


30.  Linctus. 

R  Theriacse,  .  .  . 
Pulv.  Tragacanthffi, 
Svrupi  Paiiiiveris,  . 
Tiiict.  Scillte,  .  . 
Acid  Suiph.  dilut. , 

Aqua^, fl.  oz.  2 

Misce. 
Dose,  from  a  half  to  two  tea- 
spoonfuls. 

31.  Lotio  Atropiae. 

R.  Atropiffi  Sulphatis,     .     gr.  1 
Aqua3  Sambuci,       .     fl.  oz.  2 
Aquae  destillat.,      ad  fl.  oz.  8 
Misce. 

32.  Lotio  Belladonnae. 

R.  Extracti  Belladonna},  gr.  40 
Aqu:e  destillat.,      .     fl.  oz.  8 
Misce. 

33.  Lotio  Belladonnae 
cum  Alumine. 

R.  Extracti  Belladonnie,    gr.  30 

Aluminis,      ....  gr.  24 

AquK  Sambuci,      .     fl.  oz.  2 

Aquffi  destillat.,     ad  fl.  oz.  8 

Misce. 

34.  Lotio  Stramonii. 

R.  Extracti  Stramonii,    .    gr.  4 
Aquas  Lauro-Cerasi,  fl.  dr.  4 
Acpue  destillat.,      ad  fl.  oz.  8 
Misce. 


FORMULARY. 


410 


35.  Lotio  Opii. 

R.  Extract!  Opii  liquidi,  gr.  30 
Aquas  Lauro-Cerasi,  fl.  dr.  4 
Aquae  destillat.,     ad  fl.  oz.  8 

36.  Lotio  Conii  cum  Opio. 

R.  Extract!  Conii,       .     .  gr.  30 
Extracti  Opii  liquidi,  min.  30 
Aquie  ferventis,      .     fl.  oz.  8 
Misce. 

37.  Lotio  Acidi  Hydrocy- 

anici. 

R.  Acidi  Hydrocyanici  dilut., 
fl.  dr.  1 
AquffiElor.  Aurantii,  fl.  oz.  2 
AquiB  destillat.,     ad  fl.  oz.  8 
Misce. 

38.  Lotio  Aluminis. 

R.  Aluminis,     .     .     .     .    gr.  6 
Aquae  destillat.,      .     fl.  oz.  1 
Misce. 

39.  Lotio  Aluminis  Mit. 

R.  Aluminis,      ....     cr.  4 


Aqu;e  destillat., 
Misce. 


1.  oz    1 


40.  Lotio  Alum,  cum  Zinci 
Sulph. 

R    Aluminis,      ....    gr.  3 
Zinci  Sulpliat.,  .     .     .    gr.  1 
Aqua3  destillat.,      .     fl.  oz.  1 
Misce. 


41.  Lotio  Evaporans. 

R.  Sp.  ^theris  nitros.,  fl.  dr. 
Aceti  aromatici,     .       min. 
Aquaj  destillat.,     ad  fl.  oz. 
Misce. 


42.  Lotio  Plumbi. 

R.  Plumbi  Acetatis,    .     . 
Acidi  Acetici  dilut. 
Aquae  destillat., 
Misce. 


min.  2 
fl.  oz.  1 


43.  Lotio  Zinci  Oxydi. 

R.  Zinci  Oxydi,      .  .     .  gr.  90 

Glycerini,      .     .  .     fl.  dr.  4 

Aquu3  Sambuci,  .     fl.  oz.  2 

Aquas  destillat.,  ad  fl.  oz.  8 

Misce. 

44  Lotio  Glycerini. 

R.  Glycerini,      .     .     .     fl.  oz.  1 
Aquae  Flor.  Aurantii,  fl.  oz.  2 
Aquae  destillat.,     ad  fl.  oz.  8 
Misce. 

45.  Lotio  Acid.  Carbolic. 

R.  Acid.  Carbolic,  pur.,  min.  4 
to  min.  8 
Aquae  destillat.,      .     fl.  oz.  1 
Misce. 

46.  Lotio  Hydrarg.  Perchlo- 
ridi. 

R.  Hydrarg.  Perchloridi,   gr.  \ 
Aquae  destillat.,      .     fl.  oz.  1 
Misce. 

47.  Lotio  Acidi  Tannici. 

R.  Acidi  Tannici,  .     .     .  gr.  30 

Sp.  Vini  rectificati,    fl.  dr.  4 

Aquae  llosae,  .     .     .    fl.  oz.  2 

Aqu£e  destillat.,     ad  fl.  oz.  8 

Misce. 

48.  Lotio  Boracis  cum  Gly- 
cerino. 

R.  Boracis,    ....      gr.  120 

Glycerini,      .     .     .     fl.  oz.  \ 

Aquae  Sambuci,      .     fl.  oz.  2 

Aquae  destillat.,     ad  fl.  oz.  8 

Misce. 

Very  useful  in  eczema  of  the 

face  and  eyelids. 

49.  Lotio  Arnicae. 

R.  Tincture  Arnic;e,       min.  30 
Aquie  destillat.,      .     fl.  oz.  1 
Misce. 


420 


FORMULARY. 


50.  Lotio  Nigra. 

R.  Calomelanos,     .     .     .  gr.  60 
Mucilag.  Acacite,  .     fl.  dr.  4 
Liquor.  Calcis,  .     ad  fl.  oz.  6 
ilisce. 


51.  Lotio  Rubra. 


rr.  1 


55.  Mistura  Salinae. 

R.  Pota.^sai  Bicarb.,    .     .  gr.  10 
Spirit.  jEtheris  nitrosi, 

fl.dr.  J 
Liq.  Ammoniae  Acetatis, 

fl.  dr.  1 
Aquae  destillat.,     ad  fl.  oz.  I 
Misce. 


R.  Zinci  Sulphati>,      . 
Sp.  Rosmarini, 
Tiiict.  Lavandulae  comp. 

aa  min.  15 
Aquae  destillat.,      .     fl.  oz.  1 
Misce. 


52.  Mistura  Antimonii  Tar- 
tarati. 

R.  Yin.  Antimonialis,    fl.  dr.  i 
Liq.  Ammon.  Acetati-s, 

fl.  dr.  1 
Tinct.  Hyoscyami,  min.  20 
Aquae  destillat.,     ad  fl.  oz.  1 


56.  Mistura  Cinnamomi. 

R.  Tinct.  Cinnamomi,     fl.  dr.  1 
Aquae  destillat., 
Misce. 


oz.  1 


53.  Mistura  Potassae 
Citratis. 

R.  Potassae  Bicarb.,    .     .  gr.  20 

Sp.  Ammon.  Aromat.  fl.  dr.  J 

Tinct.  Aurantii,     .     fl.  dr.  h 

AquiB  destillat.,      .  fl.  oz.  li 

To   be  taken  in  effervescence 

•with 

Acid.  Citric,  gr.  14 
dissolved   in  one   tablespoonful 
of  water. 

The    Sp.    Ammon.    Aromat. 
may  be  omitted  if  desired. 

54.  Mistura  Chloroformi 
cum  Ammonia. 

R.  Ammoniw  Carb.,  .  ".    gr.  3 

Sp.  Chloroformi,  .  min.  15 

Tinct.  Aurantii,  .  fl.  dr.  ^ 

Aquaj  destillat.,  .  fl.  oz.  1 

Misce. 


57.  Mistura  Cinnamomi  cum 
Acido. 

R.  Tinct.  Cinnamomi,  fl.  dr.  ^ 
Acid.  Nitro-Muriatic. 

dilut.,  ....  min.  10 
Aquae  destillat.,      .     A-  oz.  1 

Misce. 

58.  Mistura  Boracis. 

R.  Boracis, gr.  60 

Sp.  ^theris  nitrosi,   fl.  dr.  4 

Syrup.  Aurantii,    .     fl.  dr.  4 

Aquae  destillat.,     ad  fl.  oz.  8 

Misce. — Dose,  1  ounce. 

59.  Mistura  Nucis  Vomicae. 

R.  Tinct.  Nucis  Vomica?, 

min.  15 
Infus.  Gentian,  comp., 

fl.  oz.  1 
Misce. 

60.  Mistura  Acidi  cum 
Tinct.  Nucis  Vomicae. 

R.  Acidi  Nitro-Muriatici 

dilut.,    ....    min.  10 
Tinct.  Nucis  Vomicje, 

min.  15 
Tinct.  Chirataj,       .    min.  15 
Aqua?  destillat.,      .     fl.  oz.  1 
Misce. 


FORMULARY. 


421 


61.  Mistura  Acidi  cum  Cin- 

chona. 

R.  Acidi  Nitro-Muriatici 

dilut.,    ....     min.  10 
Tinct.  Cinchonas,   .     fl.  dr.  ^ 
Decoct.  Cinchona?,      fl.  oz.  1 
Misce. 

62.  Mistura  Cinchonae  cum 

Opio. 

R.  Extract.  Cinchonre  Flav. 

liquid., ....     min.  15 

Acidi  Nitrici  dilut.,  min.  10 

Tinct   Opii,  .       min.  5  to  10 

Aqufe  destillat.,      .     fl.  oz.  1 

Misce. 

63.  Mistura  Cinchoniae. 

R.  Cinchoni;e  Di.«ul[)hatis,  gr.  3 
Acidi  Sulphuric!  dilut., 

min.  10 
Aqupe  destillat.,      .     fl.  oz.  1 
Misce. 

64.  Mistura  Quiniae. 

R.  Quinitfi  Sulphatis,  .     .    gr.  1 
Acid.  Sulphuric,  dilut., 

min.  10 
Tinct.  Aurantii,     .     fl.  dr.  J  , 
Aquae  destillat.,      .     fl.  oz.  1  j 
Misce.  I 

65.  Mistura  Quiniae  cum 
Ferro. 

R.  Quiniffi  Sulphatis, 

Ferri  Sulphatis,     .    aa  gr.  1 
Acidi  Sulphurici  diluti, 

min.  5 
Aquae  destillat.,      .     fl.  oz    1 
Misce. 

66.  Mistura  Ferri  Perchlo- 
ridi  cum  Q,uinia. 

R.  Quinite  Sulphatis,  .     .    gr.  1 
Tinct.  Ferri  Perchlorid., 

min.  5 
Acidi  Nitrici  diluti,     min.  5 
Aqua3  destillat.,     ad  fl.  oz.  1 
Misce. 


67.  Mistura  Ferri  Sulphatis. 

R.  Ferri  Sulphatis,      .     .     gr.  1 
Acidi  Sulphurici  diluti, 

min.  10 
Aqua;  destillat.,      .  fl.  oz.  IJ 
Misce. 

68.  Mistura  Ferri  Perchlo- 

ridi. 

R.  Tinct.  Ferri  Perchloridi, 

min.  10 
Aquc-e  destillat.,      .     fl.  oz.  1 
Misce. 

69.  Mistura  Ferri  Perchlo- 

ridi cum  Acido. 

R.  Tinct.  Ferri  Perchloridi, 

min.  10 
Acid.  Hydrochloric,  dilut., 

min.  10 
Aquas  destillat.,      .  fl.  oz.  1^ 
Misce. 

70.  Mistura  Ferri  Perchlo- 
rid. cum  Strychnia. 

R.  Tinct.  Ferri  Perchloridi, 

min.  10 
Liquor.  Strychnine,       min.  5 
Aqufe  destillat.,      .     fl.  oz.  1 
Misce. 

71.  Mistura  Ferri  cum 
Tinct.  Digitalis. 

R.  Tinct.  Ferri  Perchloridi, 

min.  10 
Tinct.  Digitalis,     .      min.  5 
Infus.  Quassiie,      ad  fl.  oz.  1 
Misce. 

72.  Mistura  Ferri  cum 

Ergota. 

R.  Tinct.  Ferri  Perchloridi, 

min.  10 

Tinct.  Ergota?,  .     .     min.  15 
Aquffi  destillat.,      .     fl.  oz.  1 
Misce. 


sn 


422 


FORMULARY, 


73.  Mistura  Potassii  lodidi 

cum  Ferro. 

R.  Potassii  lodidi,       .     .     gr.  3 

Potassiu  BiciU'b.,     .     .    gr.  5 

Ferri  ct  Ammoiiiic  Citrutis, 

gr.  5 

Aquffi  destillat.,      .     fl.  oz.  1 

Misce. 

74.  Mistura  Potassii  lodidi. 

U.  Pota.?sii  lodidi,       .     .    gr.  3 
Potass.  Bicarbonat. ,  .    gr.  5 
Infusi  Quassiffi,     .       fl.  oz.  1 
Misce. 

75.  Mistura   Potass.  lodidi 

cum  Ammonia. 

R.  Potassii  lodidi.,  .  .  gr.  3 
Potassse  Bicarb  ,  .  .  gr.  5 
Ammon.  Carbonat.,  gr.  3 
Tinct.  Calumbae,  .  fl.  dr.  J 
Aqiuo  destillat.,  ad  fl.  oz.  1 
Misce. 

76.  Mistura  Potassii  lodidi 

cum  Colchico. 

R.  Potassii  lodidi,  .  .    gr.  2 

Potassae  Bicarb.,  .  .  gr.  10 

Tinct.  Colchici,  .  min.  10 

Aqiise  destillat.,  .  fl.  oz.  1 

Misce. 

77.  Mistura  Potassii  lodidi 

et  Bromidi. 

R.  Potass.  lodidi,  .  .     .    gr.  3 

Potass.  Bromidi,  .     .    gr.  5 

Potass.  Bicarb.,  .     .    gr.  5 

Tinct.  Calumbae,  .     fl.  dr.  i 

Aqua3  destillat.,  ad  fl.  oz.  1 

78.  Mistura  Potassii  lodidi 
cum  Hydrarg.  Perchloridi. 

R.  Hydrarg.  Perchloridi,    gr.  1 

Potassii  lodidi,       .     .  gr.  GO 

Tinct.  Calumb;c,    .     fl.  oz.  2 

Aqua3  destillat.,     ad  fl.  oz.  6 

Misce. 

Dose,   two  teaspoonfuls    in   a 


glass  of  water  two  or  three  times 
a  day. 

79.  Mistura    Potassii    Bro- 

midi. 

R.  Potass.  Bromidi, 

gr.  5  to  gr.  10 

Potass.  Bicarb.,      .     .    gr.  5 

Tinct.  Calumbae,    .     fl.  dr.  ^ 

Infus.  Calumbie,    .     fl.  oz.  1 

Misce. 

80.  Mistura  Hydrarg.  Per- 

chloridi. 

R.  Liquor.  Hydrarg.  Per- 
chloridi,    .     .     .     fl.  dr.  1 
Tinct.  Cinchonae,   .     fl.  dr.  ^ 
Aquae  destillat.,      .     fl.  oz.  1 
Misce. 

81.  Mistura  Terebinthinae. 

R.  Olei  Terebinthinre,     min.  15 
Mucilaginis  Acaciie,  fl.  dr.  1 
Aqua3  Pimentiu.  ad  fl.  oz.  IJ 
Misce. 

82.  Mistura  Magnesiae  Com- 
posita. 

R.  Magnesiae  Carbonatis 

pond., gr.  10 

Magnesiie  Sulphatis,  .  gr.  (JO 
Aquaj  Menthte  Piperitic, 

fl.  oz.  1^ 
Misce. 

83.  Mistura  Rhei  Comp. 

R.  Khei  Pulveris,  .  .  .  gr.  15 
Magnesiae  Carbonatis,  gr.  10 
Sp.  Ammon.  Aromat., 

fl    dr    .} 
Tinct.  Ehei.,      .     .     fl.  dr.  1 
Aqute  destillat.,    ad  fl.  oz.  1^ 
Misce. 

84.  Pilula  Aloes  cum  Ferro. 

R.  Extracti  Aloiis  Socotrina^, 
Ferri  Sulpiiatis, 
Pulv.  Zingiberis,  .      :'ia  gr.  1 
Theriaca^,     ....       q.  s. 
Misce. 


FORMULARY, 


423 


*85.  Pilula  Aloes  cum  Nuce 
Vomica. 

R    Extracti  Niicis  Vomioppjgr.  ^ 
Extracti  Aloes  Socotrinse, 

gr.  1 
Extracti  Hyoscyami,      gr.  2 
Misee. 

86.  Pilula  Cinchoninse  cum 
Ferro. 

R.  Cinchoniriie  Sulphatis, 

Ferri  Sulplnitis,     .     aa  gr.  1 
Confectionis  liosse  Caninaj, 
gr,  3 
Mi  see. 

87.  Pilula  Colocynthidis 
cum  Hyoscyamo. 

R.  Extrae'ti  Colocynthidis 

compositi,  ....    gr.  3 
Extracti  Hyoscyami,      gr.  2 
Misee. — Dose,  1  or  2. 

88.  Pilula  Colocynthidis 
cum  Hydrargyro- 

R.  Pilula;  Hydrargyri, 
Es:tracti  Colocynthidis 

compositi, .     .     .     aa  gr.  2 
Extracti  Hyoscyami,      gr.  1 
Misee. 

89.  Pilula  Colocynthidis 

cum  Rheo. 

R.  Pilulffi  Colocynthidis 

com  p., gr.  3 

PiiuliTe  Ehei  comp.,     .    gr.  3 
Extracti  Hyoscyami,      gr.  2 
Mix  and  divide  into  two  pills. 
Dose  1  or  2. 

90.  Pilula  Calomelanos  cum 
Colocynthide. 

R.  Hvdrargvri  Subchloridi, 

gr.  1 
Extracti  Colocynthidis 

compositi,       .     .     .    gr.  3 
Ipecacuanha}  Pulveris,   gr.  ^ 
Misee.  —  Dose,  1  or  2. 


91.  Pilula  Elaterii  Com- 

posita. 

R.  Elaterii,    .    '.     .     .     .    gr.  ^ 
Extract.  Aloes  Socotrinte, 

Extracti  Hyoscyami,      gr.  3 
Misee. 

92.  Pilula  Colchici  Comp. 

Extract.  Colchici  Acetici, 

gr.  1 
Pulv.  Ipecacuanha  comp., 

gr.  4 
Extracti  Hyoscyami,      gr.  1 
Misee. 

93.  Pil.  Cannabis  Comp. 

R.  Extract.  Cannabis  Indicie, 

Extract.  Belladonnas,     gr.  ]( 
Extract.  Aconiti,   .     .    gr.  ^ 
Misee. 
One  pill  at  night  or  when  in 
great  pain. 

94.  Pil.  Calomel,  cum  Opio. 

R.  Hydrarg.  Subchloridi, 

gr.  1  ad  gr.  2 
Pulv.  Opii,    .     gr.  I  ad  gr.  ^ 
Confect.  Rosa3  Caninae,    q.  s. 
Misee. 

95.  Pil.  Hydrarg.  cum  Opio. 

R.  Pil.  Hydrarg.,  .     .     .    gr.  4 
Pulv.  Upii,    .     .     .     .    gr.  i 
Misee. 

96.  Pil.  Hydrarg.  lodidi 
Virid. 

R.  Hydrarg.  lodidi  Virid.,  gr.  1 
Extracti  Lactucae,       .    gr.  2 
Misee. 

97.  Unguentum  Belladonnse. 

R.  Extracti  Belladonna',     o/..  ^ 
Clyceriiii,      .     .     .     li.  dr.  1 

Adipis, vz.  I 

Misee. 


; 


424 


FORMULARY. 


98.  Unguent.  Belladonnae 
Comp. 

R.  Hydrarg.  Ainmoniati,   gr.  5 
Extract.  Belladonnae,    gr.  10 

Adipis, oz.  1 

Misce. 
To  be  rubbed  on  the  forehead 
and  temple.  The  surface  may 
be  then  covered  with  a  piece  of 
tissue  paper  to  prevent  the  hair 
getting  into  it. 

99.  Unguent.  Hydrarg.  cum 
Belladonna. 

R.  Extract.  Belladonnae,   gr.  60 
Unguent.  Hjdrarg.,   gr.  420 
Misce. 
To  be  rubbed  into  the  temple 
and  around  the  brow. 

100.  Unguentum  Hydrar- 
gyri  cum  Opio. 

R.Opii, gr.  60 

Unguenti  Hydrargyri, 

gr.  4-0 
Misce. 

101.  Unguentum  Opii. 

R.  Opii, gr.  60 

Adipis,      ....      gr.  420 
Misce. 

102.  Unguent.  Hydrarg. 
Nitratis  Dilut. 

R.  Unguent.  Hydrarg. 

Nitratis,     ....  gr.  20 
Unguent.  Cetacei,       gr.  120 
Misce. 


103.  Unguent.  Hydrarg. 
Nitric-Oxyd.  Dilut. 

R.  Unguent.   Hydrarg.  Ni- 

tric-0.\yd.,      .     .  .  gr.  40 

Unguent.  Cetacei,  gr.  240 
Misce. 

104.  Unguent.  Plumbi  cum 
Balsam.  Peru. 

R.  01.  Lini,  .     .     .     .     fl.  dr.  4 

Emplast.  Plumbi,  .     gr.  240 

Bal.-am.  Peru,    .     .     min.  30 

Recommended      by      Pagen- 

stecher  in  severe  cases  of  Tinea 

Tarsi.     It  is   to   be   spread    on 

lint  and  applied  to  the   lids  at 

bedtime. 

105.  Unguent.  Hydrarg. 
Biniodid. 

R.  Hydrarg.  Biniodid., 

gr.  5  to  gr.  10 

Unguent.  Cetacei, .     .    oz.  1 

Misce. 

A  mercurial  counter-irritant. 

In  applying   this  ointment  the 

fingers  should  be  covered  with 

a  glove. 

106.  Unguentum  Stramonii. 

{Middlesex  Hospital.) 
R.  Foliorum  Stramonii  re- 

centium,     .     .     .     .     lb.  ^ 

Adipis, lb.  2 

Mix  the  bruised  leaves  with 
fat  and  expose  to  a  mild  heat 
until  the  leaves  become  friable, 
then  strain  through  lint. 


FORMULARY. 


42; 


FORMULARY  FOR  CHILDREN. 


107,  Mistura  Salina. 

R.  Liquor.  Ammoniie  Citra- 

tis, fl.  dr.  4 

Sp.  ^Etheris  nitrosi,   fl.  dr.  3 
Syrup.  Tolutjini,    .     fl.  dr.  4 
Aquffi  destillut.,      ad  fl.  oz.  4 
Misce. — Dose,  one  dessert- 
spoonful every  four  hours. 


108.  Mistura  Antimonii  Tar- 
tarati. 

R.  Vini  antimonialis,      fl.  dr.  2 
Liq.  Amnionic  Citratis, 

fl.  dr.  4 
Syrup.  Althaese,      .     fl.  dr.  3 
Aquae  destillat.,     ad  fl.  oz.  4 
Misce. — Dose,  one  dessert- 
spoonful between  2  and  4  years 
of  age ;    one   tablespoonful    be- 
tween 4  and  8. 


109.  Mistura  Potassae  Chlo- 

ratis. 

R.  Potassaj  Chloratis,      .  gr.  24 
Acid.  Hydrochloric,  dilut., 

min.  24 

Syrupi  Aurantii,    .     fl.  dr.  4 

Aquje  destillat.,      .     fl.  oz.  4 

Misce. — One  tablespoonful 

three  times  a  day. 

110.  Mistura  Cinchonae  cum 

Acido. 

R.  Extract.  Cinchonae  flav. 

liquid.,  ....    min.  40 
Acidi  Nitrici  diluti,  min.  40 
Syrupi  Aurantii,    .     fl.  dr.  3 
Aquic  destillat.,     ad  fl.  oz.  4 
Misce. — Dose,    one    table- 
spoonful. 


111.  Mistura  Cinchonae  cum 

Infus.  Rosae. 

Extract.  Cinchona;  flav. 

liquid.,  .     .     .     .    fl.  dr.  1 

Syrup.  Aurantii,    .     fl.  dr.  4 

Infusi  Eosaj  comp.,  ad  fl.  oz.  G 

Misce. — One  tablespoonful 

twice  a  day. 

112.  Mistura  Cinchonae  cum 
Tinct.  Belladonnae. 

R.  Extract.  Cinchon;e  flav. 

liquid.,       .     .     .       min.  5 

Acid.  Nitric,  dilut.,     min.  3 

Tinct.  Belladonna},       min.  3 

Aquaa, ....     ad  fl.  oz.  J 

Misce. — For  a  child  from 

4  to  7  years  of  age. 

113.  Mistura  Potassii  Brom. 
cum  Tinct.  Belladonnae. 

R.  Potassii  Bromid.,  .     .    gr.  2 

Tinct.  Belladonnje,       min.  3 

Aqua3  destillat.,      .     fl.  oz.  J 

For  a  child  between  4  and  7 

years  of  age. 

Misce. 

114.  Mistura  Ferri  lodidi. 

R.  Syrup.  Forri  lodidi, 


Glycerini, 

Aqua3  destillat., 
Misce. 


in.  10  to  20 
.  fl.  dr.  I 
ad  fl.  oz.  A 


115.  Mistura  Potassii  lodidi 
cum  Ferro. 

R.  Potassi  lodidi,        .     .    gr.  8 
Ferri  et  Ammoniae  Citra- 
tis,     gr.  24 

Sacchari  albi,     .     .     .  gr.  60 
Aquas,       .     .     .    ad  fl.  oz.  4 
Misce. — Onedessert-spoon- 
ful  for  a  dose. 


36* 


426 


FORMULARY. 


116.  Mistura  Ferri  Citratis. 

R.  Ferri  et  Ammoniae 

Citratis,      .     .     .     .  gr.  30 
Sacchari  albi,     .     .     .  gr.  60 
Aqua}  destillat. ,      .     fl.  oz.  4 
Misce. — One  dessert  to  a  table- 
spoonful  twice  a  day. 

117.  Mistura  Ferri  Hypo- 

phosphitis. 

R.  Syrup.  Ferri  Hypophos- 

'pliitis,   .     .     min.  15  to  3^" 
Aqute  destillat.,      .     fl.  oz.  ^ 
Misce. 

118.  Pulvis  Cinchonae  cum 

Soda. 

R.  Pulvoris  Cinchonae  flavie, 
Sodaj  Bicarbonatis, 

partes  sequales. 
Misce. — Dose,  gr.  5  to  gr.  10. 


119.  Pulv.  Ferri  Carbonat. 

cum,  Saccharo. 
{P.  B.) 

Dose,  gr.  3  to  gr.  6,  once  or 
twice  a  day. 

120.  Pulvis  Ipecac.  Comp. 
cum  Potass.  Nitrat. 

R.  Pulvis  Ipecac,  corup.,    gr.  1 
Potassffi  Nitratis,    .     .    gr.  2 
Misce. 

121.  Pulvis.  Hydrarg.   cum 
Creta  cum  Saccharo. 

R.  Pulvis  Hydrarg.  cum 

Creta, gr.  1 

Pulvis  Sacchari  albi, .    gr.  2 
Misce. 

122.  Pulvis  Alterativus. 

R.  Hydrarg.  cum  Creta,      gr.  1 

Sodje  Bicarbonatis,     .    gr.  2 

Pulvis  Khei,      .     .     .    gr.  3 

Misce. — Dose,  gr.  6  to  gr.  12. 


123.  Pulv.  Hydrarg.  cum 
Creta  cum  Rheo. 

R.  Hvdrargvri  cum  Cretii,  gr.  1 
Pulv.  liliei,  .     .     .     .    gr.  2 
Misce. — Dose,  gr.  3  to  gr.  8. 

124.  Pulvis  Scammonii  cum 
Jalapa. 

R.  Pulv.  Scammonii,       .    gr.  1 
Pulv.  Jalapie,    .     .     .    gr.  3 
Misce. — Dose,  gr.  3  to  s^r.  8. 


125.  Pulvis  Calomel,  cum 
Rheo. 

R.  Pulv.  Khei,  .     .     .     .    gr.  4 
Hydrargyri  Subchloridi, 
Pulv.  Cretae  Aromaticae. 

aa  gr.  1 
Misce. — Dose,  gr.  3  to  gr.  8. 


126.  Pulvis  Calomel,  cum 
Jalapa. 

R.  Pulv.  Jalapa^,    .     .     .    gr.  4 
Hydrargyri  Subchloridi, 
Zingiberis,     .     .     .    aa  gr.  1 
Misce. 
Dose,  gr.  3  to  gr.  6. 


127.  Pulvis  Calomel,  cum 
Scammonio. 

R.  Pulv.  Scammonii,       .    gr.  4 
Hydrarg.  Subchloridi, 
Sacchari  puriticati,     aa  gr.  1 
Misce. — Dose,  gr.  3  to  gr.  6. 


128.  Pulvis  Calomel,  et 
Scammon.  cum  Jalapa. 


R.  Hydrargyri  Subchloridi, 

gr. 

Scammonii,  ....    gr. 

Pulv.  Jalapae,    .     .     .    gr, 

Mi.sce. — Dose,  gr.  3  to  gr.  7. 


TEST-TYPES  FOR  ASTIGMATISM. 
By  Dr.  Orestes  M.  Pray. 


^ 


liliiiii 


»^^   5m  A»w\V 
Xs    X    \AVV 


w   JJ  1 


INDEX. 


Abscess  of  cornea,  51 
eyelid,  372 
orbit,  379 
Abscission  of  the  eye,  79 
Accommodation,  diseases  of,  260 
Acute  inflammatory  glaucoma,  134 
Alternating  strabismus,  283 
Amaurosis,  238 
causes  of,  243 

from  disease  of  cerebrum,  243 
cerebellum,  244 
spinal  cord,  244 
loss  of  blood,  246 
reflex  irritation,  246 
uterine  derangements,  245 
monocular,  247 
signification  of,  238 
Amblyopia,  247 

signification  of,  247 
Anatomy  of  fourth  nerve,  309 
frontal  sinus,  409 
sixth  nerve,  309 
third  nerve,  305 
Anchyloblepharon,  374 
Aneurism  of  orbit,  391 

by  anastomosis  of  orbit,  394 
difi'use  or  consecutive,  392 
true  and  false,  391 
treatment  of,  395 
Anomalies  of  refraction.  260 
Anterior    chamber,    dislocation    of 
lens  into,  187 
staphyloma  of  the  sclerotic,  80 
Arlt,   Dr.,  operation  for  entropion, 

351 
Artificial  pupil,  112 

with  a  broad  needle   and  Tyr- 
rell's hook,  113 
by  iridodesis,  1 14 
incision  of  iris,  115 
excision  of  iris,  116 


Artificial  eyes,  325 
Asthenopia,  280 

from  hypermetropia.  280 

insufficiency    of  the  internal 
recti,  281 
Astigmatism,  275 

compound.  277,  278 

irregular,  276 

mixed,  278 

regular,  277 

simple,  277 

to  ascertain  the  presence  of,  278 

treatment  of,  278 
Atrophy  of  optic  nerve,  236 

from  tobacco,  238 
Atropic  cup  of  optic  nerve,  237 

Black  cataracts,  157 
Blennorrhcea,  328 
Blepharospasm,  362 
Bone  on  the  choroid,  224 
Bowman,    Mr.,   operation   for   arti- 
ficial pupil,  1 16 
on  capsulo-lenticular  cataract, 
176 
ectropion,  356 
spoon    for  traction    operation. 
164 
Broad  needle,  155 
Burns  and  scalds  of  eye,  317 


Canaliculus,  to  slit  up  the,  335 
Canular  forceps,  186 
Capsular  cataract,  149 
opacities,  181 

varieties  of,  181,  182 
treatment  of.  183 
Capsule,   opaque,   needle    operation 
for,  183 


430 


INDEX. 


Capsule,  opaque,  operation  with  two 
needles  for,  1S5 
canular  forceps  for,  186 
Capsulo-lenticular  cataract,  149,  176 
Caries  of  orbit,  389 
Cataract,  149 
black,  157 
capsular,  149,  175 
cnpsulo-lenticular,  149,  175 
congenitnl  or  infantile,  150 

operations  for,  152-155 
cortical,  150 
diabetic,   149,  176 
fluid,  177 
hard,  149,  156 
treatment  of,  157 
operations  for,  158-175 
cnsualties  after  an  operation 

for.  170 
treatment  after  extraction  of, 
168 
lamellar,  150 
nuclear,  157 
pj'ramidal,  176 
secondary,  181 
senile,  149,  157 
soft,  149 
striated,  157 
traumatic,  178 

treatment    by    flap    extraction, 
158 
Graefe's  modified    linear  ex- 
traction, 164 
Jacob,<on"s  extraction,  167 
linear    extraction.    Gibson's, 

153 
Macnamara's  operation,  168 
Mooren's  extraction,  167 
Pagenstecher's       extraction, 

167 
solution,  152 
suction,  155 
traction  operation.  162 
Catarrhal  ophthalmia,  13 
Chalazion,  367 

Choroid,  deposits  of  bone  on,  224 
diseases  of.  217 
hemorrhage  from,  225 
injuries  of,  226 
medullary  cancer  of,  230 
melanotic  cancer  of,  230 
melanotic  sarcoma  of,  230 
sarcoma,  of,  230 
tubercles  in,  225 
tumors  of,  229 


Choroiditis,  disseminated,  217 

suppurative,  221 
Choroido-iritis,  121,  122 
Chromo-pseudopsis,  250 
Chronic  glaucoma,  138 

interstitial  corneitis,  45 
ophthalmia,  15 
Cilia  forceps,  346 
Ciliary  muscle,  par.nlysis  of,  296 
spiism  of,  297 
staphyloma,  80 
Cocciuss  ophthalmoscope,  254 
Color-blindness,  250 
Concomitant  strabismus,  285 
Congenital  cataract,  150 
Conical  cornea,  69 
operations  for,  73 
[  Conjunctiva,  diseases  of,  13 
I  foreign  bodies  on,  85 

'  cysts  of,  41 

dislocation  of  lens  beneath,  192 
ecchymosis  of,  41 
injuries  of,  41 
lacerations  of,  42 
warts  of,  41 
Conjunctivitis,  acute,  13 
Consecutive  or  secondary  glaucoma, 

139 
Convergent  strabismus,  286 
Coredialysis,  118 
Cornea,  diseases  of,  43 
conical.  69 
fistula  of,  65 
leucoma  of,  68 
opacity  of,  from  lead,  69 
staphyloma  of,  76 
partial,  76 
complete,  77 
ulcers  of,  58 

chronic  vascular,  64 
superficial,  58 
nebulous,  59 
transparent,  59 
deep,  60 

crescentic  or  chiselled,  62 
sloughing,  61 
injuries  of,  85 
abscess  of,  51 
foreign  bodies  on,  85 
paracentesis  of,  52 
penetrating  wounds  of,  88 
Corneitis,  43 

chronic  interstitial,  45 
diffuse  suppurative,  50 
general  treatment  of,  47 


INDEX. 


431 


Corneitis,  marginal,  52 

strumous,  46 
Corneo-iiitis,  57 
Cortical  cataract,  150 
Critchetfs  canaliculus  director,  335 
operation  for  staphyloma,  78 
iridodesis,  1 14 
divergent  strabismus,  293 
spoon  for  traction  operation,  164 
Crossed  diplopia,  21)9 
Cup,  glaucomatous,  135 
Curette,  155 
Cyclitis,  82 

Cysticercus  on  iris,  105 
Cystotome,  Graefe's,  160 
Cysts  of  iris,  104 

lachrymal  gland,  339 
retina,  216 
eyelid,  367 
sebaceous,  369 


Dacryo-adenitis.  338 
Dacryo-cystitis,  332 
Dacryops,  339 

fistulosus,  340 
Deposits  of  bone  on  choroid.  224 
Dermoid  tumors  of  cornea,  40 

cysts,  369 
Detachment  of  retina,  209 
causes  of,  2(19 
treatment  of,  212 
Diabetic  cataract,  149,  176 
Dichromic  vision,  250 
Diffuse  suppurative  corneitis,  50 
Diplopia,  298 
crossed,  299 
homonymous,  298 
Diphtheritic  ophthalmia,  26 
Direct   examination    with    ophthal- 
moscope, 259 
Diseases  of  choroid,  217 
conjunctiva,  13 
cornea  and  sslerotio,  43 
crystalline  lens,  149 
eyelids,  342 
frontal  sinus,  409 
iris.  93 

lachrymal  apparatus,  327 
optic  nerve,  231 
orbit,  379 
retina,  195 
vitreous,  142 
Dislocation   of    lens    into    anterior 
chamber,  187 
vitreous,  189 


Dislocation,    beneath    conjunctiva, 
191 
partial,  192 
Disseminated  choroiditis,  217 
Distension  of  frontal  sinus,  409 
Distichiasis,  346 
Divergent  strabismus,  287 
Dixon,  Mr.,  on  granular  lids,  33 


Ecchymosis  of  conjunctiva,  41 

eyelids,  370 
Ectropion,  351 

treatment  of,  353-358 
Eczema  of  eyelids,  345 
Embolism  of  central  artery  of  retina, 

213 
Entropion,  348 

chronic.  349 

spasmodic,  348 

treatment  of,  350 
Epicanthus,  369 
Epiphora,  327 

from  obstruction  by  tumors,  335 
Episcleritis,  84 

Epithelial  cancer  of  eyelid,  365 
Excision  of  eye,  323 
Exophthalmic  goitre,  396 
Extraction  of  cataract.     See  Cata- 
ract, Treatment  of 
Exudative  choroiditis,  217 
Eye,  excision  of,  323 

rupture  of,  through  sclerotic, 90 
Eyelashes,  operation  for  the  removal 

of,  347 
Eyelids,  diseases  of,  342 

abscess  of,  372 

blepharospasm,  362 

distichiasis,  346 

ecchymosis  of,  370 

ectropion,  351 
operations  for  relief  of,  353- 
358 

eczema  of,  345 

entropion,  348 

operations  for  relief  of,  350 

epicanthus,  369 

epithelial  cancer  of,  365 

hordeolum,  344 

nictitation,  363 

paralysis  of  orbicularis,  360 

ptosis,  358 

rodent  cancer  of,  365 

syphilitic  ulcers  of,  364 

tiuea  tarsi,  342 


432 


INDEX. 


Eyelids,  trichiasis,  345 

tumors  of,  367 

naevus,  3fi8 

tarsal  cysts,  367 

wounds  of.  372 


Field  of  vision,  to  ascertain  the  per- 
fection of,  252 
to  mnp  out  the,  253 
Fine  needle,  153 
Fistula  of  cornea,  65 

lachrymal  gland,  340 
sac,  333 
Flap  extraction  of  cataract,  158 
accidents  during,  161 
remarks  on.  161 
Fluid  cataract,  177 
Fluidity  of  vitreous,  146 
Focal  illumination  of  eye,  260 
Forceps,  canular,  186 
cilia,  346 
ivis,  112 
Foreign  bodies  on  conjunctiva,  85 
cornea,  85 
in  orbit,  384 

vitreous,  147 
within  the  eye,  313 
Formulary,  415 
Fourth  nerve,  paralysis  of,  309 

anatomy  of,  309 
Fractures  of  orbit,  382 
Frontal  sinuses,  anatomy  of.  410 
sinus,  distension  of,  410 
causes  of,  410 
treatment  of,  413 


Glaucoma,  132 

acute  inflammatory,  134 
chronic  or  simple,  138 
consecutive  or  secondary,  139 
Glaucomatous   cup,    characteristics 

of,  135 
Glioma  of  the  retina,  214 

treatment  of,  216 
Globe,  to  ascertain  tension  of,  140 
involuntary  oscillations  of,  151 
Goitre,  exophthalmic,  396 
Gonorrhoea!  ophthalmia,  22 
Graefe's  operation  for  conical  cor- 
nea, 74 
staphyloma  of  cornea,  80 
strabismus,  291 
hooks  for  traction  operation, 166 
knife  for  cataract,  165 


Graefe's  modified  linear  extraction 

operation,  164 
Granular  lids,  28 
Granulations,  28 

true,  28 

vesicular,  28 
Graves's  disease,  396 
Gunpowder,  injuries  from,  320 


Hard  cataract,  149,  156 
Hemorrhage  into  anterior  chamber, 
117 

between  choroid  and  retina.  226 
choroid  and  sclerotic,  226 

into  the  vitreous,  148,  228 
Hemeralopia,  248 
Homonvmous  diplopia,  298 
Hook,  Tyrrell's,  114 
Hordeolum,  344 
Hyalitis,  142 

simple,  142 

suppurative,  143 
Ilydrophthalmia,  75 
Hypermetropia,  270 

absolute,  271 

acquired,  270 

facultative,  271 

latent,  271 

manifest,  270 

ophthalmoscopic      appearances 
in,  273 

original,  270 

peculiarities  of  eye  in,  273 

relative,  271 

to  ascertain  the  degree  of,  271 

treatment  of,  271 
Hypopion,  61 


Indirect  examination  with  ophthal- 
moscope, 258 
Inflammation  of  choroid,  217 
ciliary  body,  82 
cornea,  43 
iris,  93 

lachrymal  gland,  338 
sac,  acute,  332 
chronic,  328 
optic  nerve,  231 
retina,  197 
vitreous,  142 
Injuries  of  eyelids,  370 

eye  from  burns  and  scalds,  317 
gunpowder,  320 
lime,  315,  316 


INDEX. 


433 


Injuries  of  eye  from  mortar,  316 
percussion  caps,  320 
small  shot,  322 
strong    sulphuric    and    nitric 

acids,  318 
vinegar  or  weak  acids,  319 
choroid,  226 
conjunctiva,  41 
cornea  and  sclerotic,  81) 
iris,  117 
lens,  178,  187 
Inoculation  for  cure  of  granular  lids, 

34 
Involuntary    oscillations    of   globe, 

151 
Iridectomy,  operation  of.  111 

knife.  111 
Irido-choroiditis,  121 
Iridodonesis,  141 
Iris  forceps,  112 
diseases  of,  93 
coloboma  of,  142 
cysticercus  on,  105 
cysts  of,  104 

functional  derangements  of,  106 
melanotic  sarcoma,  or  carcino- 
ma of,  106 
operations  on.  111 
prolapse  of,  119 
tremulous,  141 
Iritis,  93 

primary,  93 
rheumatic,  98 
secondary,  94 
serous,  100 
suppurative,  101 
syphilitic,  97 
traumatic,  102 

Jacobson's   operation  for    cataract, 
167 

Keratitis,  43 
Kerato-globus,   75 
Keratome,  111 
Keratonyxis,  152 

Knife,  cataract,  for  flap  extraction, 
159 
Graefe's, 'for  cataract,  165 
secondary,  for  cataract,  160 
Stilling's,   for  lachrymal  stric- 
ture, 330 
Wecker's,  for  slitting  up  canal- 
iculus, 336 

Lacerations  of  conjunctiva,  42 


Lachrymal   apparatus,   diseases    of, 
327 
gland,  diseases  of,  338 

chronic  enlargement  of,  341 
cysts  of,  339 
hypertrophy  of,  341 
inflammation  of,  338 
fistula  of,  340 
removal  of,  337 
sac,  acute  inflammation  of,  332 
chronic  inflammation  of,  328 
fistula  of,  333 
stricture  of,  329 

Stilling's  knife  for,  330 
Weber's  conical  sound  for, 
329 
obliterations  of,  336 
Lagophthalmos,  360 
Lamellar  cataract,  150 
Lateral  illumination  of  eye,  260 
Lens,  crystalline,  diseases  of,  149 
dislocation    of,     into     anterior 
chamber,  187 
into  vitreous,  189 
beneath  conjunctiva,  191 
partial  dislocations  of,  192 
Leucoma  of  cornea,  68 
Levator  palpebral,  paralysis  of,  358 
Liebreich's  operation  for  strabismus, 
292 
ophthalmoscope,  254 
Lime,  injuries  from,  315 
Linear  extraction  of  cataract,  153 
Lodgement  of  foreign  bodies  in  the 
eye,  313 

Maenamara's  operation  for  cataract, 

168 
Marginal  corneitis,  52 
Meibomian  cysts,  367 
Melanotic  sarcoma  of  iris,  100 

carcinoma  of  iris,  106 
Modified  linear  extraction,  164 
Mooren's  operation  for  cataract,  167 
Moorfield's  operation  for  strabismus, 

290 
Mortar,  injuries  from,  316 
Mucocele,  328 
Muscse  volitantes,  143 
Mydriasis,  106 
Myopia,  262 

general  directions  for,  269 
rules  for  selection  of  glasses 
in.  267 
ophthalmoscopic    appearances 
in,  264 


37 


434 


INDEX. 


Myopia,  treatment  of,  265 
Myosis,  108 


NiBvus  of  eyelid,  368 
Necrosis  of  orbit,  389 
Needle,  broad,  154 

fine,  153 

operation  for  capsular  opacities, 
183,  184 
Neuro-retinitis,  231,  233 
Nictitation,  363 
Night-blindness,  248 
Nuclear  cataract,  157 
Nystagmus,  151 


Obliteration  of  lachrymal  sac,  336 

Onyx,  51 

Opacity  of  cornea  from  lead,  69 

capsule  of  lens,  181 

vitreous,  143,  145 
Operations.     Sef-  separate  headings. 
Ophthalmia,  catarrhal,  13 

chronic,  15 

diphtheritic,  26 

Egyptian,  21 

gonorrhceal,  22 

granular,  28 

neonatorum,  18 

phlyctenular,  64 

purulent,    of    newly-born    in- 
fants, 18 
contagious,  21 

pustular,  17 

scrofulous,  54 

sympathetic,  126,  127 

tarsi,  342 
Ophthalmitis,  221 
Ophthalmoscope,  the,  253 

binocular,    of    Giraud-Teulon, 
257 
Laurence  and  Heisch,  257 

Coccius's,  254 

direct  examination  with,  259 

fixed,  of  Liebreich,  256 
Messrs.  Smith  &  Beck,  257 

heterocentric,  253 

homocentric,  253 

how  to  work  with  the,  257 

indirect  examination  with,  258 

Liebreich's  portable,  254 

Weiss's  portable,  256 

Zehender's,  256 
Optic  nerve,  atrophy  of,  236 

diseases  of.  231 


Optic  neuritis,  descending,  231 
Orbicularis,  paralysis  of,  360 
Orbit,  abscess  of,  379 

acute   inflammatory   exmlation 
into,  406 

aneurisms  of,  391 

caries  of,  389 

foreign  bodies  in,  384 

fractures  of  the  bones,  386 

necrosis  of,  389 

penetrating  wounds  of,  386 

periostitis  of,  386 

tumors  of,  399 

1.  Those  which  originate  with- 

in orbit,  400 

2.  Those    which      commence 

within  eye,  403 

3.  Those  which  originate  be- 

yond ej-e  or  orbit,  403 
tumors  of,  bony  and  cartilagin- 
ous, 400 
cysts  of,  401 
fibrous  tumors  of,  400 
recurrent  fibroid  tumors  of,  401 
Orbital  tumors,  treatment  of,  404 
Oscillations,   involuntary,  of  globe, 
151 


Pagenstecher's   operation    for  cata- 
ract, 168 
Panophthalmitis,  221 
Paracentesis  of  cornea,  52 
Paralysis  of  ciliary  muscle,  309 
fourth  nerve,  309 
sixth  nerve,  310 
third  nerve,  306 
portio   dura  of  seventh   nerve, 

360 
external  rectus,  310 
inferior  rectus,  308 
internal  rectus,  308 
superior  rectus,  308 
superior  oblique,  309 
levator  palpebrte,  359 
orbicularis,   360 
Paralytic   aifections   of  muscles    of 
eye,  302 
from  intra-cranial  disease,  303 
intra-orbital  disease,  303 
blood-poisoning,  304 
reflex  irritation,  304 
treatment  of,  311 
Penetrating  wounds  of  cornea   and 
sclerotic,  88 
orbit,  386 


INDEX. 


435 


Percussion  caps,  injuries  from,  320 
Periodic  strabismus,  283 
Periostitis  of  orbit,  386 

acute,  388 

chronic,  386 
Peritomy,  36 

Piiysiological  cup  of  optic  nerve,  136 
Phlyctenular  ophthalmia,  54 
Pinguecula.  40 
Plaster,  injuries  from,  316 
Posterior   staphyloma   of  sclerotic, 

220 
Presbyopia,  274 

treatment  of,  274 
Pricker  for  cataract  operations,  160 
Primary  iritis,  93 
Prisms,  action  and  uses  of,  299 

to  ascertain  the  presence  of  bi- 
nocular vision,  299 

to  test  the  strength  of  the  mus- 
cles of  the  eye,  300 

to  wear  as  spectacles  to  correct 
diplopia,  302 
Prolapse  of  iris,  119 
Pterygium,  38 
Ptosis,  359 
Pupil,  artificial,  112 
Purulent  ophthalmia  of  newly-born 
infants,  18 

or  contagious  ophthalmia,  21 
Pustular  ophthalmia,  17 
Pyramidal  cataract,  176 


Refraction,  anomalies  of,  260 
Retina,  diseases  of,  195 

cysts  of,  216 

detachment  of,  209 
causes  of,  209 

embolism  of  central  artery  of, 
213 

glioma  of,  214 

hyperasmia  of,  195 

tumors  of,  214 
Retinitis,  i97 

albuminurica,  199 

apoplectica,  204 

pigmentosa,  207 

syphilitica,  202 
Retinal  apoplexy,  204 
Rheumatic  iritis,  98 
Rodent  cancer  of  eyelid,  365 


Sclerotieo-choroiditis,  posterior,  220 
Sclerotic  diseases,  43 


Sclerotic,    anterior   staphyloma  of, 
80 

posterior  staphyloma  of,  220 

penetrating  wounds  of,  88 

rupture  of,  90 
Scrofulous  ophthalmia,  54 
Sebaceous  cysts,  369 
Secondary  cataract,  181 

glaucoma,  139 

iritis,  94 
Senile  cataract,  149,  157 
Serous  iritis,  100 
Seton,  in  vascular  ulcer  of  cornea,  65 

staphj'loma  of  cornea,  80  •> 

Short  sight.      Sre  Myopia 
Simple  glaucoma,  138 
Sixth  nerve,  paralysis  of,  310 

anatomy  of,  310 
Small  shot,  injuries  from,  322 
Snow-blindness,  250 
Soft  cataract,  149 

operations  for,  152-156 
Sparkling  synchysis,  146 
Spasm  of  ciliary  muscle,  297 
Speculum,  spring-stop,  113 
Spoons   for   traction    operation    for 

cataract,  164-166 
Spud  for  removal  of  foreign  bodies, 

85 
Squint.     See  Strabismus 
Staphyloma,    anterior,   of  sclerotic, 
80 

posterior,  of  sclerotic,  220 

ciliary,  80 

of  cornea,  76 

operations  for,  78-80 
Stilling's  knife,  330 
Strabismus,  282 

alternating  or  binocular,  283 

causes  of,  284 

concomitant,  285 

convergent  or  internal,  286 

Critchett's  operation  for  diver- 
gent, 294 

divergent  or  external,  287 
following  divisions   of  inter- 
nal recti,  293 

Graefe's  operation  for,  291 

hooks    used    in    operation    for, 
290-291 

Liebreich's  operation  for.  292 

Moorfields  operation  for,  290 

paralytic,  303 

periodic,  283 

primary  deviation  in,  285 

secondary  deviation  in,  285 


436 


INDEX. 


Strabismus,   to   note  the  extent  of 
the,  284 

treatment  of,  288 
Streatfeild's  operation  for  entropion, 

350 
Striated  cataract,  156 
Stricture  of  nasal  duct,  329 
Strong  acids,  injuries  from,  318 
Strumous  corneitis,  46 
Suction  operation  for  cataract,  155 
Suppurative  corneitis,  50 

choroiditis,  221 

iritis,  101 
•  Symblepharon,  375 
Sympathetic  irritation,  126 

ophthalmia,  126-127 
Synchysis,  146 

scintillans,  146 
Syndectomy,  36 
Syphilitic  iritis,  97 

ulcers  of  eyelid,  364 


Taylor,  Mr.,  spoon  for  traction  ope- 
ration, 166 
Teale,  Mr.  T.  P.,  operation  for  sym- 
blepharon,  378 

suction  operation,  155 
Tension  of  globe,  to  ascertain,  140 
Third  nerve,  paralysis  of,  306 

anatomy  of,  306 
Tinea  tarsi,  342 
Trachoma,  28 

Traction  operation  for  cataract,  162 
Traumatic  cataract,  178 
treatment  of,  179 

iritis,  102 

treatment  of,  103 
Tremulous  iris,  141 
Trichiasis,  345 
Tumors  of  choroid,  229 

conjunctiva,  41 

cornea  and  sclerotic,  40 

eyelids,  367 


Tumors  of  frontal  sinus,  410 

iris,  106 

orbit,  399 

retina,  214 

sebaceous    or     dermoid,     near 
orbit,  369 
Tyrrell's  hook,  114 
Test-types,  427 


Ulcers  of  eyelid,  364 
epithelial,  365 
rodent,  365 
syphilitic,  364 
of  cornea,  58 

chronic  vascular,  64 

superficial,  58 

nebulous,  59 

transparent,  59 

deep,  60 

crescentic  or  chiselled,  62 

sloughing,  61 


Vinegar,  injuries  from,  319 
Vitreous  humor,  diseases  of,  142 
dislocation  of  lens  into,  189 
fluidity  of,    146 
foreign  bodies  in,  147 
hemorrhage  into,  148,  228 
inflammation  of,  142 
opacities  of,  143,  145 


Warts  on  conjunctiva,  41 
Weak  acids,  injuries  from,  319 
Weber's  conical  sound,  329 
Wecker's  canaliculus  knife,  335 
White  atrophy  of  optic  nerve,  236 
Wounds  of  eyelids,  372 


Zehender's  ophthalmoscope,  255 


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